Extracorporeal membrane oxygenation (ECMO) has become a critical rescue therapy for pregnant and peripartum patients experiencing life-threatening cardiac or respiratory failure that is refractory to standard treatments. Pregnancy induces unique physiologic changes that influence ECMO initiation, cannulation, and management, necessitating specialized approaches to optimize outcomes for both mother and fetus. Pharmacologic challenges include altered drug kinetics and the risks associated with placental drug transfer, while anticoagulation strategies require a careful balance between thrombosis and bleeding, particularly around delivery. Obstetric management involves continuous fetal monitoring, individualized timing of delivery, and multidisciplinary coordination among critical care, obstetrics, neonatology, and anesthesiology teams. Evidence from case series, registries, and meta-analyses indicates favorable maternal survival, especially with venovenous ECMO, although fetal outcomes vary depending on gestational age and clinical circumstances. Ethical considerations are complex, emphasizing maternal autonomy alongside fetal well-being, often requiring decisions amid considerable uncertainty. Emerging technologies, such as artificial placenta systems, may offer future support options. Despite encouraging results, significant gaps remain in prospective data, standardized fetal monitoring, and ethical guidance. This review synthesizes current knowledge and underscores the need for ongoing research and multidisciplinary collaboration to improve care for pregnant patients requiring ECMO.