Background: Spontaneous Hemoperitoneum (SH) presenting as acute abdomen is a life-threatening event that can occur in absence of trauma in patients on chronic anticoagulation or in those with inherited coagulopathies. The present study aims to describe patient characteristics, etiology, clinical course, important considerations in management and outcomes in women with acute abdomen due to SH with background coagulopathy. Methods: Clinical course of six non-pregnant women admitted for acute abdomen due to SH of gynaecological or unknown origin with coagulation abnormalities was retrospectively reviewed. Results: All six patients presented with hemodynamic collapse and coagulation dysregulation either due to chronic anticoagulants use or DIC-like picture as a sequelae of severe COVID 19 disease. Emergent surgical intervention was needed in all but one patient, who responded to conservative management. Intensive resuscitation and rapid emergency correction and reversal of coagulopathy was essential in all cases especially prior to surgery. Ovulatory or corpus luteal bleeding was identified in 2 patients and ruptured right ovarian hemorrhagic cyst was found in one, while no cause for SH could be identified in rest. Two patients died due to associated severe coronavirus disease while all others had stable post-resuscitation and post-operative course. Conclusion: SH secondary to coagulation abnormalities can be catastrophic. Prompt clinical and CT guided evaluation of acute abdomen should be done in those with background coagulopathy of any cause with fatal SH kept as an important differential diagnosis. Emergency reversal of anticoagulation and definitive management should be undertaken with multidisciplinary collaboration.