As such, the primary goal of this systematic review and meta-analysis was to assess and investigate the potential value of low PAPP-A levels in the prediction of subsequent HDPs, PTB, and SGA/FGR in twin pregnancies and its association with the development of GDM, intrauterine death (IUD) of at least one twin, and birth weight discordance (BWD) among the fetuses, hoping to determine the clinical relevance of this biochemical marker and the potential necessity for additional investigation of its utility in complications other than the detection of common aneuploidies. The gene discussed is PAPPA; the disease is gestational diabetes.