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To explore the hypothesis that selective placental pathology affecting the nonpresenting twin is a significant contributory factor mediating the smaller size at birth of nonpresenting dichorionic twins.We conducted a retrospective cohort study of all dichorionic twin deliveries in a single tertiary center between 2002 and 2015 where by departmental policy, all placentas from multifetal gestations are routinely sent for pathologic examination. Maternal charts, neonatal charts, and pathology reports were reviewed. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage, and chronic villitis. Comparison of neonatal outcomes and placental abnormalities was made between all nonpresenting and all presenting twins as well as within twin pairs.A total of 1,322 women with dichorionic twins were studied. Nonpresenting twins were smaller at birth compared with the presenting cotwin starting at 32 weeks of gestation (birth weight [±standard deviation] 2,224±666 g compared with 2,278±675 g, P=.036). Nonpresenting twins had smaller placentas (361±108 g compared with 492±129 g, P<.001) as early as 24 weeks of gestation. Nonpresenting twins had higher odds for any placental abnormality (adjusted odds ratio [OR] 1.91, 95% confidence interval [95% CI] 1.63–2.23), small placenta (adjusted OR 4.69, 95% CI 3.75–5.88), and maternal vascular malperfusion (OR 2.75, 95% CI 2.32–3.27) compared with their presenting cotwins. In nonpresenting twins, the presence of maternal vascular malperfusion pathology was associated with lower birth weight compared with their presenting cotwin during the third trimester.The lower birth weight of nonpresenting fetuses in dichorionic twin pregnancies is correlated with a higher rate of placental maternal vascular malperfusion pathology.