Aim: The management of a missed diagnosis of heterotopic pregnancy complicated by uterine perforation. Background: Heterotopic pregnancy (HP) is an exceptional condition where at least two pregnancies are present simultaneously at different implantation sites and one of them is located in the uterine cavity. Case description: We report an interesting near miss case of a 23-year-old P3L3A1 with a heterotopic pregnancy who was misdiagnosed as a case of acute abdomen with hemoperitoneum due to uterine perforation, postsurgical evacuation for an intrauterine pregnancy. Exploratory laparotomy was performed which confirmed the diagnosis of heterotopic pregnancy where the ectopic pregnancy was located in the right fallopian tube which was managed by right-sided salpingectomy and uterine rent repair was performed. Conclusion: A high index of suspicion followed by an early surgical laparoscopic/laparotomy intervention can minimize maternal morbidity and mortality in a heterotopic pregnancy. Clinical significance: How a benign and assumably routine case of missed abortion escalated to an eventual diagnosis of a heterotopic pregnancy.