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Re: Iatrogenic perforation of intertwin membrane after laser surgery for twin‐to‐twin transfusion syndrome. S. H. P. Peeters, T. T. Stolk, F. Slaghekke, J. M. Middeldorp, F. J. Klumper, E. Lopriore and D. Oepkes. Ultrasound Obstet Gynecol 2014; 44: 550–556

In this retrospective analysis of a cohort of 338 pregnancies treated with laser for twin-to-twin transfusion syndrome, Peeters et al. looked at the relationship between iatrogenic perforation of the dividing membrane (iMAT) and pregnancy outcome. They found an increased incidence of adverse outcome in pregnancies with iMAT. One of the strengths of the study is that documentation of perforation of the membrane at surgery was part of the clinical protocol, as was observation of the membranes at follow-up scans. However, recent evidence suggests that cord entanglement and monoamnionicity in themselves (after excluding congenital abnormalities) are not associated with increased perinatal mortality or morbidity1,2. Moreover, iatrogenic monoamnionicity differs from spontaneous amnionicity in many respects: in the current series, cord entanglement was observed in only 12% of iMAT cases after birth, while it is observed almost universally in spontaneous monoamniotic pregnancies; the placental angioarchitecture of these two groups is also quite different3. As acknowledged by Peeters et al., the increase in adverse outcomes may have been an effect of a technically challenging procedure rather than of iMAT itself: cases with iMAT needed repeat intervention at least twice more often than did those without, which carries an additional risk of preterm birth. Furthermore, the observation of iMAT may have prompted aggressive management of the pregnancy, as testified by the fact that 16/67 cases were delivered electively between 32 and 35 weeks just because of the diagnosis of iMAT. This was probably overtreatment, as use of this approach to deliver early is starting to be questioned even in natural monoamniotic pregnancies. Only in one case of double fetal demise was a direct effect of iMAT – cord entanglement – considered to be the ‘most likely’ cause of death. In conclusion, although this article describes elegantly one of the many fascinating aspects of fetoscopic surgery for twin-to-twin transfusion syndrome, iMAT may just represent a distractor in the quest for (modifiable) determinants of outcome of this treatment.