A 37-year-old patient (gravida 10, para 0–1–8-0) with class III obesity, obstructive sleep apnoea requiring continuous positive airway pressure and previous pulmonary emboli presented at 19 + 6 weeks’ gestation with severe treatment naïve pulmonary hypertension.

Termination of pregnancy was recommended but declined. Following multidisciplinary planning, awake peripheral venoarterial extracorporeal membrane oxygenation (ECMO) was initiated under local anaesthesia at 23 + 1 weeks to support further foetal maturation. At day 4 of ECMO support acute hypoxaemia necessitated intubation, conversion to venoarterial-venous ECMO and urgent classical caesarean delivery. A 550-g female was delivered and admitted to neonatal intensive care. Postpartum haemodynamic improvement permitted deescalation to venovenous ECMO. The patient was liberated from extracorporeal support after 17 days and despite both suffering morbidity, mother and infant have since returned home. This case illustrates complex obstetric management decisions and highlights the necessity of multidisciplinary engagement in navigating the nexus between maternal autonomy and resource-intensive care.