Acute respiratory failure in pregnancy is a rare but life-threatening event that requires specialized management between the obstetric and critical care teams. There are very few case reports regarding the treatment of the mother and the fetus in the case of respiratory failure during pregnancy. We report a case of a 30-year-old woman who was at 31 weeks, 5 days gestation and was found unresponsive at home with a suspected drug overdose. On admission, the patient was unresponsive after intubation that was difficult because of facial and upper airway edema. Fetal heart tones were assessed and found to be in the 130s, with no fetal movement detected. The patient was diagnosed with acute respiratory failure, hypoxic ischemic encephalopathy, hypertension, gestational diabetes, asthma, and pneumonia; in addition, urine toxicity screening was positive for opiates. Initial treatment included therapeutic hypothermia, mechanical ventilation, electroencephalogram (EEG) monitoring, electronic fetal monitoring, bedside ultrasound with biophysical profile, sedation, magnesium for preeclampsia prophylaxis, an antihistamine for significant facial edema, steroids for fetal lung maturity, and an insulin drip to manage diabetes. A repeat cesarean was performed on Day 2 of hospital admission due to worsening neurological status. The neonate was born with Apgar scores of 3 at 1 min and 4 at 5 min and transferred to NICU. On Day 6 of admission, an EEG concluded a diagnosis of postanoxic myoclonus that was consistent with diffuse cerebral dysfunction and injury. Findings and the prognosis were discussed with the family, and the decision to withdraw support was made. The woman was a registered organ donor, and donation after cardiac death occurred on Day 6 of hospital admission. The newborn was discharged to home on Day 49 of life; there was continued concern for possible hypoxic-ischemic sequelae, although EEG, end-organ function lab values, and evolving examination were reassuring. Coordination of care with a multidisciplinary team is necessary to provide the best and most appropriate care to a very complex obstetric patient. In the absence of published evidence-based practice guidelines, in regard to treatment options, case reports and clinical judgment need to be used in the decision-making process.