A 32-year-old woman arrived at the emergency department with agonising abdominal pain that had been getting worse for two days. She was breathless, her heart was racing, and every touch to her abdomen caused sharp discomfort. What initially appeared to be severe abdominal distress soon revealed a far more dangerous condition.

Doctors found that both of her ovarian endometriotic cysts — commonly known as “chocolate cysts” — had ruptured. These cysts form when endometriosis affects the ovaries, causing old blood to collect inside. When they burst, the internal bleeding can be life-threatening. In her case, nearly 1.5 litres of blood had pooled inside her abdomen, sending her into hemorrhagic shock.

Once the diagnosis was confirmed, the medical team quickly prepared for emergency surgery. The complexity of the situation became clearer once the laparoscopic procedure began. A massive 15 × 12 cm cyst had ruptured on the right ovary, while another 6 × 5 cm cyst was leaking on the left. Thick adhesions had glued portions of the bowel and omentum together, completely blocking the pouch of Douglas — a common area affected in severe endometriosis. To make matters worse, endometriotic deposits were found extending as high as the liver surface.

Leading the procedure, Dr. Richa Arora Miglani, Head of Minimally Invasive Gynaecology & Robotic Surgery of RG Hospita, Pitampura, Delhi, said the intensity of internal bleeding and the extent of adhesions made the surgery extremely challenging. The team carefully excised both cysts, removed the adhesions, washed out the blood, and reconstructed the right ovary — all while ensuring the ovaries were preserved to protect the woman’s future fertility.

“This case was particularly challenging due to the extent of adhesions and the severity of internal bleeding,” Dr. Miglani said. “Through timely diagnosis and advanced laparoscopic intervention, we were able to manage the condition effectively while preserving the patient’s reproductive potential.”

The patient recovered smoothly after surgery and was discharged in stable condition — a reminder of how quickly untreated endometriosis can escalate, and how crucial timely diagnosis and expert care are in such rare, high-risk emergencies.