This is a case of a 35-year-old primigravid who was initially diagnosed by ultrasound (done abroad) at 12 weeks AOG with a live, singleton fetus having a sacrococcygeal mass. Congenital anomaly scan done from another local institution at 19 weeks AOG, showed a live, singleton fetus with the same aforementioned defect and a floating amorphous, echogenic structure inferior to and separate from the fetus, seemingly with extremities but without a cephalic pole, probably an acardiac twin. A repeat congenital anomaly scan at 23 weeks AOG done in our institution revealed a live, breech male fetus (pump twin) with what seemed to be another set of fetal lower limbs with talipes attached to the sacrococcygeal area of the well-developed fetus. Three-vessel umbilical cord of the pump twin was noted with normal SID ratio on color doppler. Ultrasound findings were suggestive of conjoined pump and acardiac twins. Patient underwent elective cesarean section at 38-39 weeks AOG, delivered an ischiopagustype, male conjoined twins (a well-developed term pump twin with an acardius acephalus twin) and another acardiac amorphous component completing a triplet. The most important factor in deciding on the correct choice of management is the early diagnosis of acardiac twin. Early diagnosis with ultrasound assists in prenatal management and counseling parents. Conservative management with close antepartum surveillance deserves consideration in cases of monozygotic twins with twin reversed arterial perfusion sequence.