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Iliopsoas abscesses, a rare complication in pregnancy, typically present as a secondary infection due to direct spread of another nearby infection.A 30-year-old multigravid patient with a 10-year history of intravenous heroin use and chronic lower-back pain, presented at 23 0/7 weeks of gestation with multiple cutaneous abscesses. As her back pain worsened during antepartum hospitalization, a primary iliopsoas abscess with underlying osteomyelitis was identified requiring percutaneous computed tomography–guided drainage along with extended-course intravenous antibiotics. After treatment and methadone detoxification, her pregnancy resulted in a successful vaginal delivery.Primary iliopsoas abscess should be considered in the differential diagnosis of low-back pain among high-risk pregnant women. Clinicians should be vigilant in identifying high-risk factors and aggressive in treating this rare and potentially fatal complication.