Heterotopic pregnancy is the presence of an intrauterine pregnancy and an extrauterine (ectopic) pregnancy. Spontaneous heterotopic pregnancy is rare with an incidence of 1:30,000 but the prevalence is increasedwith assisted reproductive technology (ART). Delayed diagnosis of heterotopic pregnancy is not uncommon, often presenting with signs ofruptured extrauterine pregnancy. This case report describes a ruptured spontaneous heterotopic pregnancy that required emergent surgery and massive transfusion.