Heterotopic pregnancy: A diagnostic challenge in early pregnancy loss

The incidence of heterotopic pregnancy (HP), the coexistence of intrauterine and ectopic pregnancies, is rare but increasing with assisted reproductive technology. This report presents the case of a 30-year-old G3P0 female and highlights the diagnostic challenges of HP, particularly in the presence of a coexisting intrauterine fetal death. Overlapping symptoms can allow an ectopic pregnancy to remain undetected, increasing the risk of complications, such as tubal rupture and hemoperitoneum. Two key sonographic findings—the tubal ring sign and the ring of fire sign—are described to aid in detecting a coexisting ectopic pregnancy. Thorough adnexal evaluation with endovaginal ultrasound remains essential for early diagnosis of HP, enabling timely intervention and reducing the risk of life-threatening outcomes.