A 37-year-old woman, BMI 56.6 kg/m², presented at 19+6 weeks’ gestation with severe respiratory failure. Her progressive dyspnoea and chest discomfort had been attributed to obesity hypoventilation and sleep apnoea for years, delaying appropriate investigations. Obesity may also complicate imaging, further contributing to diagnostic delays1. By presentation, she was oxygen-dependent with severely impaired functional capacity.
Imaging and right heart catheterisation confirmed pulmonary veno-occlusive disease with moderate pulmonary hypertension (PH). Despite maximal medical therapy, her condition deteriorated, requiring ICU admission, mechanical ventilation, and initiation of venovenous extracorporeal membrane oxygenation (VV-ECMO) to prioritise fetal survival in line with the patient’s wishes. Caesarean delivery was performed at 23+5 weeks, and the neonate required NICU. Postpartum, the patient suffered limb ischaemia, requiring thrombectomy and fasciotomy, further complicating recovery. Her baby has since been discharged and is doing well.
Lung transplantation was considered; however, her BMI exceeded eligibility thresholds (BMI >35 kg/m² being an absolute contraindication2). Obesity likely contributed to PH progression through mechanisms such as hypoventilation, obstructive sleep apnoea, chronic inflammation and increased intravascular volume3. A very low energy diet and compassionate access to tirzepatide, a dual GLP-1/GIP receptor agonist, were initiated. Over 15 weeks, she achieved a 22% weight reduction (127.4 kg to 99 kg), improving transplant candidacy.
This case underscores the impact of weight bias in delaying PH diagnosis and highlights obesity as both a contributor to PH severity and a barrier to definitive treatment. Tirzepatide demonstrates significant potential in facilitating rapid, medically supervised weight loss, enhancing access to life-saving interventions such as lung transplantation. Wider, equitable access to tirzepatide in Australia, similar to the UK’s targeted rollout4, may improve outcomes for patients with class 3 obesity and severe comorbidities, reduce healthcare costs, and address health inequities.