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Background: Heterotopic pregnancy, the coexistence of intrauterine and ectopic gestations, is a rare and potentially life-threatening condition, posing a significant challenge in patients with advanced maternal age and comorbidities. Case Presentation: A 38-year-old multigravida (G4P2L2A1) presented to the emergency department with three months of amenorrhea, two days of vaginal bleeding, and six hours of lower abdominal pain. She was a known case of Rheumatoid Arthritis on long-term oral steroids and had prior obstetric complications, including a missed abortion and peripartum blood transfusion due to a cervical tear during her first delivery. On clinical examination, she was tachycardic (104/min) with stable blood pressure (120/70 mmHg). Abdominal examination revealed right iliac fossa tenderness, and pelvic examination showed cervical motion and right forniceal tenderness. Transabdominal ultrasound revealed a viable intrauterine pregnancy, a 4.2?3.2 cm hetero-echoic clot in the right adnexa, and significant hemoperitoneum, indicating a ruptured right tubal ectopic pregnancy. Management: After initial resuscitation, the patient underwent an emergency laparotomy. Intraoperatively, 500 ml of hemoperitoneum, 350 ml of clots, and a ruptured right tubal pregnancy near the fimbrial end were identified. A right salpingectomy and left tubal ligation were performed. The left adnexa appeared normal. As she had completed her family, suction evacuation of intrauterine products of conception was performed. No intraoperative blood transfusion was required. Outcome: The postoperative period was uneventful. Histopathological examination confirmed a ruptured right tubal ectopic pregnancy with a gestational sac and products of conception from the uterus. The patient recovered well and was discharged on the seventh postoperative day. Conclusion: This case underscores the importance of early diagnosis and prompt surgical intervention in heterotopic pregnancies, particularly in high-risk patients. Timely management ensured a successful outcome in a complex clinical scenario. Keywords: Heterotopic pregnancy, ruptured ectopic pregnancy, salpingectomy, intrauterine pregnancy, emergency laparotomy, obstetric emergency.