One of the greatest physiologic challenges during pregnancy is to maintain an adequate supply of oxygenated blood to the uteroplacental circulation for fetal development. This challenge is magnified under conditions of limited oxygen availability. High altitude impairs fetal growth, increases the incidence of preeclampsia, and, as a result, significantly increases the risk of perinatal and/or maternal morbidity and mortality. This review summarizes the clinical consequences and physiologic challenges that emerge when pregnancy and high altitude coincide and highlights the adaptations that serve to protect oxygenation and fetal growth under conditions of chronic hypoxia.