Abstract Background: - Twin pregnancies are risks during pregnancy, labor, and delivery as well as during postnatal period as the result of preterm delivery, antepartum hemorrhage, chronic disease, and postpartum hemorrhage. The probable risk factors reported include chorionicity, maternal age, and body mass index, and smoking, use of assisted conception, gestational diabetes, and hypertensive disorders of pregnancy. Although several studies have reported adverse outcomes of twin pregnancies globally and in some parts of Ethiopia, there is limited and inconsistent local evidence regarding the prevalence and predictors of adverse maternal and perinatal outcomes among twin pregnancies at Tibebe Ghion Hospital. In particular, data specific to this referral setting are scare. Therefore, this study aimed to assess the prevalence and predictors of adverse maternal and perinatal outcomes in twin pregnancies at Tibebe Ghion Specialized Hospital, Bahirdar, Ethiopia. Objective: - To determine the prevalence and predictors of adverse maternal and perinatal outcomes among twin pregnancies managed at Tibebe Ghion Specialized Hospital, Bahirdar, Ethiopia. Methods: - A retrospective hospital based cross-sectional study design was used to conduct the study on women admitted at obstetrics unit as twin pregnancy and who gave birth from August, 2024 to August, 2025. The questionnaires were used to collect information from patients’ charts and hospital register. All the collected data were recorded by SPSS version 25.0 for analysis. Bivariate and multivariate analysis was also be carried out to see and understand the effect of each independent variable on maternal and perinatal outcome. Results: A total of 353women with twin pregnancies were included in the study. The composite adverse maternal outcome was observed in 40% of participants, with anemia as the most common complication (78.7%). Cesarean section was performed in 51.8% of deliveries, and 53% of births occurred before 37 weeks gestation. Grand multiparity (parity ≥5) significantly increased the odds of adverse maternal outcomes (AOR=3.4; 95% CI: 1.37–8.62), along with a history of twin pregnancy (AOR=2.9; 95% CI: 1.08–8.04) and interpregnancy interval under 24 months (AOR=1.5; 95% CI: 1.27–3.16). Pregnancy complications were strongly associated with adverse perinatal outcomes (AOR=6.1; 95% CI: 2.96–12.43), whereas medication or supplement use during pregnancy was protective (AOR=0.45; 95% CI: 0.24–0.87). Conclusions: This study revealed a high prevalence of adverse maternal and perinatal outcomes among twin pregnancies At Tibebe Ghion Hospital. The prevalence of composite adverse maternal outcomes was 40% while composite adverse perinatal outcomes were observed in 83% (high) of twin A and ( high) 85% of twin B. Grandmultiparity, short interpregnancy interval, and previous history of twin pregnancy were significant predictors of adverse maternal outcomes, where pregnancy related complication and adverse maternal outcomes were strongly associated with adverse perinatal outcomes. Strengthening antenatal care, early identification of high risk twin pregnancies and timely obstetric interventions are essential to reduce adverse outcome.