To examine the incidence of life-threatening (near-miss) complications, including hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome occurring in women with preeclampsia in the Grampian region of Scotland between 1981 and 2000.All women who were resident in a geographically determined region (the Grampian region of Scotland) and who developed moderate to severe preeclampsia in the time period 1981 to 2000 were identified from the Aberdeen Maternity and Neonatal Databank. All complications occurring antepartum, intrapartum, or postpartum in these pregnancies were listed as International Classification of Diseases (ICD) codes and significant complications were identified from these. The cases of HELLP syndrome were identified by case note review. Data were analyzed using Statistical Package for Social Scientists (SPSS).A total of 4188 cases of preeclampsia were identified over the 20-year period. Six percent (approx. 1 in 16) of preeclamptics developed one or more major systemic complications. The incidence of placental abruption and eclampsia was 2.8% and 1.65%, respectively. Hematological complications were most common, with reduced platelets accounting for about half of these cases; although, a definite diagnosis of HELLP syndrome could only be made in 13 cases over 20 years. After adjusting for gestational age, a woman was 1.14 times more likely to have a caesarean delivery (95% C.I. 1.08, 1.20) if she had complicated preeclampsia. She was also more likely to have a stillbirth [Odds Ratio (O.R.) = 1.45 (95% C.I. (confidence interval) 1.02, 2.29)] or a neonatal death [O.R. = 2.25 (95% C.I. 1.12, 4.260].There has been a gradual decline in the rate of preeclampsia in the Grampian region of Scotland over the time period 1986 to 2000; although, the percentage of pre-eclamptics who developed one or more complications has not decreased appreciably. In fact, the incidence of eclampsia and placental abruption has increased in the most recent five years. The presence of complications in preeclampsia is associated with a poor neonatal outcome.