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Thank you for revising your manuscript to address the concerns of the reviewers. Reviewer 2 now recommends acceptance and I am satisfied that the comments of reviewer 1 have been addressed. The manuscript is now ready for publication.
[# PeerJ Staff Note - this decision was reviewed and approved by Celine Gallagher, a PeerJ Section Editor covering this Section #]
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The authors have successfully addressed all the minor revisions I previously requested. They have added a clear data availability statement, justified their exclusion criteria, acknowledged the limitations regarding lifestyle variables, and expanded on the potential for the study to be underpowered for rare outcomes. The revisions have significantly improved the clarity and transparency of the manuscript. The article is now a strong candidate for publication.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and that any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
Title:
The title, “The Role of Pre-Pregnancy Overweight in Gestational Diabetes, Hypertension, and Macrosomia,” is clear and informative, effectively conveying the study's objective.
Abstract:
The abstract effectively summarizes the study’s objectives, methods, key findings, and conclusions.
Introduction
The introduction provides information on the consequences of prenatal overweight on pregnancy, delivery, and newborn health. However, it would be relevant to strengthen the rationale of this study (lines 79-82).
It would also be important to provide the prevalence of obesity and prenatal overweight in China and globally to illustrate the scope of the issue.
In lines 80-82, you wrote that some studies did not account for the complex interaction between multiple adverse effects on the mother and newborn. Which are these studies? The references are not provided.
Figures & Tables
The figures and tables are clear and well-structured, presenting the data effectively.
Material and Methods
The methodology is well-structured and generally provides an adequate level of detail for reproducibility. The study spans January 1, 2022, to December 31, 2022, which seems adequate. The chosen statistical methods (chi-square, Fisher's exact tests, logistic regression) are appropriate for the study objectives. However, the following aspects need further clarification:
• What is the rationale for the inclusion of women married for the first time and the exclusion of women in their second marriage? Are considered criteria for inclusion and exclusion?
• Did you consider the most recent prenatal BMI of the pregnant women?
• Why did you not consider comorbidities such as diabetes mellitus and chronic hypertension as confounding factors?
Results
The study provides valuable and clinically relevant insights into the association between maternal overweight before pregnancy and adverse outcomes for both the mother and newborn, including gestational diabetes, hemolytic syndrome, macrosomia, prematurity, and low birth weight, within a Chinese population. The analysis of 748 patients represents a significant sample size, allowing for meaningful statistical comparisons. The plausibility and credibility of the presented data are generally strong, as the statistical methods (logistic regression, chi-square, and Fisher's exact tests) are suitable for the dataset.
Discussion
The discussion corresponds closely with the results presented in the study. The author has compared these results with those of other studies to establish a correlation.
The findings of this study are relevant and consistent with the objectives set by the authors and the context of this research, which aimed to determine the association between maternal overweight before pregnancy and adverse outcomes for both the mother and the newborn, including gestational diabetes, hemolytic syndrome, macrosomia, prematurity, and low birth weight, within a Chinese population.
Conclusion
The conclusion generally aligns with the study’s findings, summarizing the key results concisely.
The manuscript is written in professional and unambiguous English. The terminology is consistent, and the structure is well organized, including clearly labeled sections, informative tables, and high-quality figures. The introduction effectively establishes the background and significance of the topic, with appropriate and up-to-date references.
The article is largely self-contained. However, the raw data availability is not clearly stated.
Issues & Suggestions for improvement:
- Language: No major corrections needed.
- Raw data availability: The authors should clarify whether the raw data supporting the findings are publicly available or not shareable due to ethical restrictions. A formal data availability statement is recommended.
The study is methodologically sound, based on a well-described retrospective cohort of 748 singleton pregnancies. The objectives are clear, and the research fills a gap in the literature by focusing on maternal overweight and adverse outcomes in a Chinese setting.
The statistical approach is appropriate, including multivariate logistic regression and restricted cubic spline (RCS) analysis to assess dose-response relationships.
Issues & Suggestions for improvement:
- Exclusion criteria: The rationale for excluding remarried women and migrant populations is not explained. This may introduce bias and limit generalizability.
- Lifestyle variables: While possibly unavailable, key confounding factors such as dietary intake, physical activity, and psychological stress were not accounted for and should be acknowledged as limitations.
Suggested text to include in the discussion:
“The exclusion of women from remarriages and migrant populations may have limited the representativeness of our sample. Future studies should consider including a broader demographic to enhance generalizability.”
“Due to limitations in the available clinical records, we were unable to adjust for lifestyle variables such as diet, exercise, or stress levels. These factors should be considered in future prospective studies.”
The findings are well-supported by the analysis. The significant associations between pre-pregnancy overweight and the risks of GDM, gestational hypertension, and macrosomia are consistent with existing literature and are clearly presented with confidence intervals and p-values.
The absence of significant associations for preterm birth and low birth weight is acknowledged, but the study is likely underpowered for these outcomes.
Issues & Suggestions for improvement:
- Power analysis: No formal power analysis is presented. It would be helpful to mention that the small number of cases limits the statistical power to detect differences in rare outcomes.
- Confounding variables: As noted above, the absence of lifestyle covariates should be framed as a limitation.
Suggested text for limitations:
“The number of cases for preterm birth and low birth weight was relatively small, possibly limiting our ability to detect statistically significant differences. This should be addressed in future larger-scale studies.”
This is a timely and important study that adds to the limited body of knowledge on maternal overweight and its consequences in East Asian populations. The use of RCS models to assess linearity in risk is a particular strength.
General suggestions:
- Add a raw data availability statement.
- Justify exclusion criteria.
- Explicitly mention the lack of lifestyle data as a limitation.
- Expand the discussion of underpowered outcomes.
Once these minor issues are addressed, the article will be a strong candidate for publication.
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