BACKGROUND: Pre-eclampsia (PET) affects 2–8% of pregnancies worldwide and remains a leading cause of maternal and perinatal morbidity and mortality. Early recognition is challenging when presentations deviate from classical patterns. Ensuring compliance with national guidelines is essential to reduce complications. This case series was presented at a departmental teaching session to highlight atypical presentations of severe PET at extreme preterm gestations, promote learning from practice, and reinforce key management principles in line with RCOG guidance. AIM:To present two cases of severe pre-eclampsia with atypical features managed at extreme preterm gestation, focusing on: (1) biomarker utility (PlGF / sFlt-1:PlGF ratio), (2) multidisciplinary escalation, (3) individualised antihypertensive choices, and (4) timing of delivery decisions. A re-audit and ongoing staff education are planned to monitor improvements in care standards. CONCLUSION: Both cases highlight that severe pre-eclampsia may present atypically at extreme preterm gestations, with epigastric pain, oedema and rising BP even without significant proteinuria. A low threshold for investigation is essential. Key priorities identified: • Maintain MgSO₄ based on clinical features, not biomarkers alone • Individualise antihypertensive regimens (especially in asthmatics) • Use PlGF/sFlt-1 ratio as an adjunct, not a standalone decision tool • Early MDT involvement: neonatology, anaesthetics, senior obstetrics • Serial fetal surveillance with Dopplers in FGR with evolving PET • Plan in-utero transfer early when clinically feasible (RCOG recommendation)

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