The worldwide incidence of ectopic pregnancy is 1.5 to 2% of which the large majority occur in the fallopian tube. Heterotopic pregnancies are rare and require a high index of suspicion especially in women with risk factors as infertility, ART, IUI, ovulation induction, prior tubal surgery, pelvic inflammatory disease, genital tuberculosis or endometriosis. Of the heterotopic pregnancies the most common combination is an intrauterine pregnancy with a tubal ectopic. Here we present a case of heterotopic pregnancy wherein both pregnancies were ectopic one of them being ovarian. This case emphasizes the need for a thorough pelvic ultrasound in early pregnancy remembering that visualization of an intrauterine pregnancy does not rule out an ectopic and visualization of an ectopic does not rule out another ectopic. Also intraoperative evaluation must be thorough in case of surgery for ectopic or corpus luteal cyst rupture or else there can be major embarrassment later in case an ectopic is missed. We must remember that when we hear hooves it is likely a horse but may well be a zebra or even both.
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