Background: Unilateral tubal twin pregnancies occur in approximately 1 of every 125,000 spontaneous pregnancies. Because of the paucity of data, little guidance for the appropriate management of a twin tubal ectopic pregnancy is available. Case Report: A 40-year-old female presented to the emergency department (ED) with a 2-day history of vaginal bleeding associated with lower abdominal pain. The patient was hemodynamically stable with signs of an acute abdomen. Pelvic examination elicited clinical findings consistent with potential ectopic pregnancy. Urine pregnancy test in the ED was positive. Serum beta-human chorionic gonadotropin was 23,359 mIU/mL, and transvaginal ultrasound showed findings concerning for a twin ectopic pregnancy. Diagnostic laparoscopy with right salpingostomy was successful, and the patient had an uncomplicated postoperative course. Conclusion: Healthcare providers should have a high index of clinical suspicion for ectopic pregnancies. Unilateral tubal twin ectopic pregnancies, while rare, can be adequately diagnosed with transvaginal ultrasound. Laparoscopic salpingostomy provides conservative and successful treatment of unilateral tubal twin gestation with short recovery time. Medical treatment with methotrexate has not been adequately studied in this clinical scenario, but further exploration of this management modality should be considered.