**How the overturning of Roe has imperiled high-risk pregnancies—and how to ensure safe patient healthcare in the future. From a leading doctor on the front lines after the Dobbs decision.** Doctors and patients confronting high-risk pregnancies have always faced profound and life-altering decisions. But after the 2022 Dobbs decision overturning Roe, many of these decisions seem impossible. As a firsthand witness to this convulsion, David Hackney, a leading physician in maternal fetal medicine, offers knowledgeable, thoughtful guidance to patients and practitioners contending with high-risk pregnancies in our new reality. Impossible Choices focuses on the practical implications of high-risk complications for people who are pregnant or considering pregnancy—including conditions such as pre-eclampsia, premature membrane rupture, or birth defects—especially in states now under abortion bans. And because maternal fetal medicine overlaps with other medical fields as pregnant patients struggle with, for instance, kidney disease, lupus, diabetes, and cancer, the book also addresses a wide array of medical questions and complications. How do we make decisions when thrown into extreme and uncertain circumstances? The author answers this question and more by painting a nuanced and clear-eyed picture of obstetrics after Dobbs, illustrating his reflections with stories from his own practice, as well as those of his wife, in pediatric oncology. Without being partisan or polemical, the book offers the informed compassion and way forward that this fraught moment in maternal medicine calls for.