Heterotopic tubal pregnancy with a naturally conceived live
• Spontaneous heterotopic pregnancy (HP) occurs in approximately 2.3% of all cases of HP

• Risk factors include assisted reproduction techniques and pelvic inflammatory disease

• The probability of an ovarian pregnancy accompanied by an intrauterine pregnancy comprises 2.3% of all cases of HP

• Surgical intervention plays a key role in the management of HP, with laparoscopic salpingectomy being the gold-standard procedure

Heterotopic pregnancy (HP) is defined as the simultaneous occurrence of an intrauterine and extrauterine gestation. Risk factors contributing to this condition are similar to those which contribute to ectopic pregnancy. While a triple heterotopic gestation through natural conception is uncommon, a patient was presented with spontaneous intrauterine twins and a concurrent tubal extrauterine gestation, where the patient also had systemic lupus erythematosus. During the seventh week of gestation, the patient presented with acute abdomen signs and hemodynamic instability; a decision was taken to perform an emergency laparotomy. Haemoperitoneum, a total torsion of the right ovary with salpinx, a ruptured tubal pregnancy, and subsequent necrosis were found intraoperatively. The patient was discharged on the sixth postoperative day and monitored throughout her whole pregnancy, with the intrauterine pregnancy progressing uneventfully. Two healthy neonates were delivered by cesarean section at 36 weeks of gestation. In conclusion, physicians treating women of reproductive age should be aware of possible HP, even in the absence of risk factors.