Objective: In this study, we compared monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies for neonatal mortality, neonatal morbidity, and clinical prospective risk prediction of very early preterm twins. Methods: This retrospective cohort study included very preterm twins discharged from the NICU of Fujian Provincial Maternal and Child Health Hospital from January 1, 2017, to January 1, 2022. According to the chorionic nature, they were divided into monochorionic diamniotic twins (MCDA group) and dichorionic diamniotic twins (DCDA group). We compared maternal conditions, neonatal mortality, the rate of treatment withdrawal within 72 hours, and the incidence of the primary neonatal outcome and predicted clinical risk for the two treatment groups. Results: A total of 118 MCDA and 198 DCDA twins were included. The iatrogenic conception rate of MCDA was significantly higher than that of DCDA (P<0.001). Major neonatal outcomes included neonatal respiratory distress syndrome (RDS), need for mechanical ventilation (MV), stage 2 or 3 necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP). Compared with the two groups, the MCDA twins had a higher risk of twin growth inconsistency >20% (P<0.001), RDS (P><0.05), and a longer duration of parenteral nutrition support (P><0.05). There were no significant differences in the rates of stillbirth and treatment withdrawal between the two groups (P>0.05). There was no significant increase in the rate of NICU admission, the length of NICU stay, and the incidence of Apgar score <7 at 5 minutes after birth, Pneumonia, bronchopulmonary dysplasia (BPD), duration of mechanical ventilation support, neonatal necrotizing enterocolitis stage 2 or 3 (NEC), patent ductus arteriosus (PDA), retinopathy (ROP), brain injury, sepsis, hypothyroidism, abnormal coagulation mechanism, moderate to severe gastroesophageal reflux (P >0.05). Logistic regression analysis of the main clinical outcomes and clinical predictors showed that the main clinical outcomes of very premature twins were related to lower birth weight in MCDA twins and were independently related to chronicity. Conclusion: MCDA twins may have more short-term complications due to unequal placental sharing. Extremely preterm twin neonates face more complications, regardless of chorionic nature.