Obstetric management of severe preeclampsia between 26 and 32 weeks' gestation presents a significant management dilemma. We examined the antenatal courses and perinatal outcomes of 67 such affected pregnancies and compared them with a group of 134 patients, matched for gestational age, who delivered after preterm rupture of membranes or preterm labor. Although the severe preeclamptic group had more patients with chronic hypertension and renal disease, 67% had no prior medical problems. The obstetric and other medical characteristics of both groups were similar. Neonatal outcomes in the severe preeclampsia group differed from those in the control group: they had lower mean birthweight, 5-minute Apgar score and umbilical arterial pH were lower, and their rates of respiratory distress syndrome and perinatal death were higher. Temporization for more than 72 hours was not possible in 60 of 67 preeclamptic pregnancies due to rapid deterioration of the mother (56 cases) or fetus (4 cases). The rate of poor neonatal outcomes in severe preeclampsia exceeded that expected with preterm delivery alone and may reflect preexisting fetal compromise, served better by early intervention and delivery.