Triple heterotopic pregnancy; ectopic tubal and twin intrauterine pregnancy

Introduction: Heterotopic pregnancy (HP) is defined as the coexistence of intra- and extra uterine gestations. We report a heterotopic triplet pregnancy with intrauterine twin gestations, presenting as hemoperitoneum, formerly misdiagnosed as corpus luteum. Materials and Methods: A 33-year-old pregnant admitted to the emergency room (ER) with cramping pelvic pain. Physical examination revealed diffuse abdominal tenderness. Hemoglobin was 6.1 mg/dl. Ultrasound revealed twin IUP with positive fetal cardiac activities and hemoperitoneum ascending to liver. Results: Laparoscopic investigation diagnosed the source of hemoperitoneum was left ampullar ruptured HP. Salpingectomy was performed. She was discharged after IUP viability was confirmed. Unfortunately, 4 weeks later, she admitted to ER, diagnosed as missed abort. Dilatation and curettage was performed. Discussion: IVF has been associated with an increased risk of both EP and HP. The incidence of HP is estimated to be 1 in 30,000 in spontaneous pregnancies. Early diagnosis of HP is often difficult because of the absence of clinical symptoms. However it is prudent to be suspicious in case of ART with pelvic pain, otherwise negligence lead to maternal mortality. In the literature case of triple heterotopic pregnancy comprising one tubal ectopic and twin IUP is really rare, our case comprises this rarity.