The actual etiology of heterotopic pregnancy is unknown, and incidence of spontaneous heterotopic pregnancy is rare; estimated at 1:30,000. This is a case report of a lady with 8 weeks period of amenorrhoea presenting with a ruptured ectopic pregnancy in shock, and a concurrent intrauterine pregnancy was diagnosed at presentation. She was managed with initial laparotomy. Subsequently patient suffered intrauterine missed miscarriage shortly after. Discussion of options which included conservative, medical or surgical management were offered to patient; she chose conservative management. She then had heavy per vagina bleeding and surgical evacuation of the intrauterine pregnancy was performed.

Management of heterotopic pregnancy remains controversial. Although it has been reported that laparotomy does not seem to interrupt intrauterine pregnancy, others have reported a 40% loss of viable fetuses. Management include sonographic guided aspiration of embryo with or without embryo killing drugs in hemodynamically stable patients. Transvaginal sonographic examination remains the gold standard in diagnosing heterotopic pregnancy, despite up to more than two thirds of heterotopic pregnancies which were not diagnosed prior to surgery.

In our case this lady had a cornual ectopic pregnancy in which a wedge resection was performed. Unfortunately 48 hours later the intrauterine pregnancy has failed. Due to the proximity of laparotomy and failed pregnancy timing and patient remained stable, she was managed conservatively after informed consent and full discussion with her. Whether cornual pregnancy management increased the incidence of failed intrauterine pregnancy thereafter, remains unknown.

Adequate counselling and judicious follow-up of the patient are the essential components of expectant management. A substantially favourable risk-to-benefit ratio should be demonstrated before the adoption of expectant management. However due to the rarity of heterotopic pregnancy, and treatment experiences are limited; it is difficult to conduct a randomized controlled trial and recommend a consensus on preferred treatment modality of heterotopic pregnancy. Therefore the treatment should be individualized, and more researches are needed.