Heterotopic pregnancy, ie, combined intrauterine and extrauterine (ectopic) pregnancy, is a rare clinical entity that may present with acute abdominal catastrophy. Most of cases reported in literature are a consequence of medical or surgical interventions like assisted reproductive techniques, tubal surgeries, intrauterine contraceptive devices, or pelvic inflammatory disease. Heterotopic pregnancy occurring spontaneously is extremely uncommon. We describe the sonographic appearance of spontaneous heterotopic pregnancy with ruptured ectopic tubal pregnancy.