Objective: To explore the incidence and risk factors of preeclampsia (PE) among high- risk pregnant women in South India. Design: Nested case-control study Setting: Tertiary referral hospital Population or Sample: Pregnant women with risk for PE. Methods: Maternal characteristics were prospectively collected, and risk factors were assessed comparatively between women with risk for developing PE and normotensive pregnant women using risk ratio (RR) (95% CI) plus multivariate analysis. One hundred and seventy-four risk group pregnant women were followed-up once in each trimester till delivery and noted for the development of PE. Main Outcome Measures: Incidence and risk factors of PE among high-risk pregnant women. Results: 67/174 women developed PE, corresponding to an incidence of 38.51% among pregnant women with risk for PE. Women in the age group of 30 and older reported a higher incidence. Maternal factors like absence of a family history of chronic hypertension, history of abortion, non-consanguineous marriage, and AB blood group were significant protective factor and sex of the new-born being female was a significant risk factor for developing PE. Conclusion: This is the first Indian study that explored the incidence and risk factors for PE among high-risk pregnant women. Incidence of PE was higher among South Indian risk population. Female infants significantly contributed to the PE risk. Funding: JIPMER Intramural Research fund. Keywords: Preeclampsia; Incidence; South India; High-risk women; Follow-up; Risk factors Tweetable abstract: The incidence of PE is 38.51% and the significant risk factor is female foetus among high-risk pregnant women.