Twin gestations are fascinating and are also high-risk pregnancies. They account for approximately 3% of all pregnancies in the United States. Major obstetrical complications associated with twin pregnancies include hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery. In addition, the death rate for twins and the rate of severe handicap in very low birth weight survivors of twin pregnancies is greater than that for singleton pregnancies. Ultrasound allows for stepwise evaluations at any time during a twin gestation. Current evidence suggests that uncomplicated diamniotic twins with concordant and appropriate growth beyond 24 weeks’ gestation should be managed conservatively and the time and mode of delivery should be determined on the basis of obstetrical history and fetal presentations. Perinatal management of the remaining twin pregnancies depends on good clinical judgment, which is improved by the use of ultrasound imaging.