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To determine the incidence of early-onset severe features preeclampsia among pregnant women and compare maternal complications and perinatal outcome characteristics of expectance and immediate delivery management with identified prognosis factors for successful expectant management.A retrospective descriptive multicenter cohort study of pregnant women diagnosed with severe features preeclampsia before 34 weeks of gestation according to the American College of Obstetricians and Gynecologists guidelines was conducted at Khon Kaen University, Srinagarind Hospital and Khon Kaen Hospital between January 1, 2015 and December 31, 2019. Medical records were reviewed for incidence of early-onset severe features preeclampsia, with maternal complications and perinatal outcome characteristics compared for expectant and immediate delivery management.In total, 42,948 deliveries were recorded during the study period. Of these, 971 were diagnosed with severe features preeclampsia (22 per 1,000 deliveries). Two hundred and sixty-five women (6.3 per 1,000 deliveries) were diagnosed with early-onset severe features preeclampsia before 34 weeks of gestation. No differences were recorded in characteristics between the expectant and delivery management groups. Perinatal outcomes were significantly different between the expectant and delivery management groups; birth weight below 1,500 g (23.5 % versus 58.9 %, p 0.001), neonatal intensive care unit (65.9 % versus 87.2 %, p 0.001); neonatal resuscitation (22.3 % versus 57.1 %, p 0.001). Birth asphyxia, stillbirth and intrapartum death only occurred in women with early-onset severe features preeclampsia in the delivery management group.Incidence of early-onset severe features preeclampsia was 6.3 per 1,000 deliveries. For women with complications such as early-onset severe features preeclampsia, expectant management significantly benefitted neonatal outcomes, with no differences in maternal outcomes compared to the immediate delivery management group. The gestational age at diagnosis of more than 30 weeks and uric acid level of less than 5.5 mg/dL (327.14 μmol/L) were significant factors for the successful expectant management.