Life-threatening ovarian apoplexy unmasking a rare congenital triad: Unicornuate uterus, pelvic renal ectopia, and ovarian maldescent.

Ovarian apoplexy is a rare but potentially life-threatening gynecologic emergency characterized by acute ovarian hemorrhage and hemoperitoneum. We report the case of an 18-year-old nulligravida who presented with sudden worsening lower abdominal pain and was initially found on imaging to have a hemorrhagic left ovarian cyst, hemoperitoneum, and an incidental right pelvic ectopic kidney. Shortly after admission, she developed hemorrhagic shock with a significant drop in hemoglobin, necessitating emergency laparoscopy. Intraoperatively, approximately 1.5 L of hemoperitoneum was evacuated, and a ruptured hemorrhagic left ovarian cyst was identified and treated. The procedure unexpectedly revealed a rare congenital triad consisting of a left unicornuate uterus, right pelvic renal ectopia, and right ovarian maldescent with a partially malpositioned fallopian tube. The patient recovered uneventfully following surgical management and blood transfusion. This rare case highlights the coexistence of life-threatening ovarian apoplexy with multiple previously unrecognized congenital urogenital anomalies, creating diagnostic and surgical challenges in the emergency setting. It underscores the importance of considering underlying anatomical variations in adolescents presenting with acute abdominal pain and hemoperitoneum, as well as the value of prompt laparoscopic intervention for both definitive treatment and accurate anatomical assessment in hemodynamically unstable patients.