The management of oncogene-driven non-small cell lung cancer (NSCLC) during pregnancy presents unique challenges due to limited safety data on targeted therapies. Anaplastic lymphoma kinase (ALK)-rearranged NSCLC is a rare but increasingly recognized entity in young women, including during pregnancy. Here, we report the case of a 37-year-old woman diagnosed with metastatic ALK-rearranged NSCLC during her first pregnancy, who was commenced on alectinib. Following this, she had a successful second pregnancy whilst being treated with alectinib (withheld during weeks 6-10 of gestation to avoid the critical period of organogenesis). Both pregnancies resulted in healthy infants with no complications or evidence of developmental delays. This case highlights the importance of a multidisciplinary approach involving oncology, maternal-fetal medicine, clinical genetics, obstetrics medicine, and obstetrics to balance maternal cancer control and fetal health. While preclinical studies of alectinib suggest teratogenic risks, this and other reported cases demonstrate its potential for safe use during pregnancy with careful planning. Pathological examination of the placenta in our case revealed no malignant cells, and maternal disease remained controlled. As targeted therapies extend survival in advanced NSCLC, more patients may contemplate pregnancy, emphasizing the need for robust evidence to guide treatment decisions. This case contributes to the growing body of evidence supporting the feasibility of managing pregnancy in patients with ALK-rearranged NSCLC using targeted therapies like alectinib, while underscoring the importance of long-term follow-up for the exposed offspring.