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BACKGROUND Hemoperitoneum resulting from a ruptured ovarian cyst is rare but potentially life-threatening, particularly in patients with underlying coagulopathies. Antiphospholipid syndrome (APS) and hereditary antithrombin III (AT III) deficiency represent an exceptionally uncommon concurrent combination. Only 3 prior cases have been documented in the literature regarding thrombotic events; however, none have described acute hemorrhagic complications or their management. CASE REPORT A 28-year-old woman presented with a 24-h history of intractable pelvic pain rated 8/10, accompanied by hypotension, tachycardia, and anemia. She had a history of double-positive APS and hereditary AT III deficiency; she was receiving prophylactic warfarin therapy. Imaging revealed a ruptured hemorrhagic ovarian cyst and moderate hemoperitoneum. Initial management included hemodynamic stabilization, fluid resuscitation, and transfusion of red blood cells and fresh frozen plasma. Anticoagulation was withheld, and a computed tomography-guided pigtail catheter was inserted for pelvic hematoma decompression. After stabilization and confirmation of hemostasis, warfarin therapy was cautiously reinitiated under close international normalized ratio (INR) monitoring. The patient achieved complete clinical recovery and was discharged in stable condition. CONCLUSIONS We present the first documented case of severe hemoperitoneum due to a ruptured ovarian cyst in a patient with concurrent APS and AT III deficiency. This case highlights the complex clinical balance between anticoagulation reversal and thromboprophylaxis in patients with dual hypercoagulable disorders. Future research should aim to develop standardized, evidence-based protocols to guide management and improve outcomes in combined thrombophilic conditions.