Association Between Hypoglycaemia at the 24–28th-Week OGTT and Obstetric and Neonatal Outcomes in Women with Gestational Diabetes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

CONGLATULATIONS ON THE INTERESTING AND WELL DESIGNED STUDY.

THE INTRODUCTION COULD BE SLIGHTY EXPANDED BETTER EXPLAINING THE EXISTING CORRELATION BETWEEN HdOGTT AND ADVERSE PERINATAL OUTCOMES ACCORDING TO THE EXISTING BIBLIOGRAPHY.

 

Comments on the Quality of English Language

THE ENGLISH LANGUAGE COULD BE IMPROVED.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is a quite interesting research article with adequate novelty. However, some points should be addressed.

• In the Abstract, the abbreviation OGGT should be explained.
• In the first two paragraphs of the Introduction section, the authors should add more analysis concerning GDM, including risk factors and complication of GDM for both the mother and her children.
• The resolution of Figure 1 should be improved.
• In teh statistical analysis section, the authors should report the normality distribution test that they used.
• Beyond the limitations of the study, the authors should also report the strengths of the study.
• The Concusion section is too small and needs more analysis. The authors should also report what studies could be performed in the future based on the results of the present study.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

General Comments:

This manuscript addresses an important topic, but it is currently difficult to evaluate due to several issues related to clarity, completeness, and methodological transparency. The paper would benefit from a thorough revision to address the points below.

Major Concerns:

1. Writing Quality and Typos:
   Numerous typographical and grammatical errors throughout the manuscript make it difficult to read and interpret. A careful proofread and editorial revision are needed.

2. Introduction and Rationale:
   The introduction lacks key background literature and a clear justification for the study. It is not clear why this specific research question is being asked, or its clinical or scientific importance. A clearly stated hypothesis is also missing.

3. Inconsistencies in Results:
   There is a contradiction in the results: the first paragraph suggests a previous history of miscarriage is associated with increased risk for hypoglycemia, yet a later section indicates a decreased risk of miscarriage. This needs clarification and consistency.

4. Inclusion/Exclusion Criteria:
   The criteria are not fully described. It is unclear whether women with pre-existing conditions such as diabetes or PCOS were excluded or included, and how that may have affected the results.

5. Definition of Hypoglycemia:
   The cut-off for hypoglycemia appears inconsistent with previous literature, which sometimes uses 40–60 mg/dL. If 70 mg/dL was chosen, please justify this choice and consider discussing its implications. Perhaps a sensitivity analysis is warranted.

6. Diagnosis of GDM and Hypoglycemia:
   It is unclear how women could be diagnosed with both GDM and have low OGTT values—was this due to different time points during the test? This requires explanation for the unfamiliar reader.

7. Covariates and Statistical Rigor:
   Covariates are not clearly specified in the results, and the statistical analysis section lacks transparency. Potential collinearity between confounding variables is not addressed, nor is adjustment for hospital site, which could influence care pathways.

8. Outcome Selection and Theoretical Framework:
   The rationale for selecting specific outcomes is unclear, especially considering that medical records may contain many more variables. The selection should be grounded in a theoretical framework or supported by prior evidence.

9. Consideration of High-Risk Populations:
   It is not clear if and how high-risk populations (e.g., based on timing of GDM diagnosis, BMI, or other risk factors) were accounted for in the analyses.

Recommendations:

• Substantially revise the introduction to include relevant literature and a clear hypothesis.

• Clarify inclusion/exclusion criteria and justify all methodological choices.

• Improve transparency and detail in the methods and results sections, particularly around statistical analyses.

• Address inconsistencies in results and ensure conclusions are supported by data.

• Proofread the manuscript carefully to correct errors and improve flow.

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The paper “association between hypoglycaemia at the 24-28th-week OGTT and obstetric and neonatal outcome in women with gestational diabetes “ is a retrospective study of pregnant women that showed hypoglycaemia during their OGTT. There was a comparison between women with and without low levels of blood glucose and an effort was made for some predictive factors to be determined, as well as obstetric and neonatal complications. The result was that age, bmi, previous miscarriage and chronic hypertension were protective factors against hypoglycaemia and it was associated with a higher risk of SGA.    My comments are:  1. In line 107 there is a typographical error. HDG is written instead of HDP.  2. The acronym OGTT should be explained at least once in each section of the text.  3. A small paragraph should be added describing the clinical implications of the findings. For example, what could be the next step after a problematic OGTT with low values.  4. The authors should clarify which the study group and the control group were. In lines 90-91 it is mentioned that women with GDM are included, but in lines 118-119 it is not clarified if those women are diagnosed with GDM.  5. The figure 1 should be rewritten, so it could represent clearier the patient selection.  6. Finally, according to iThenticate report there is a 41% of plagiarism. This needs the attentions of the authors. 

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript has sufficiently been improved. The resolution of Figure 1 needs improvenment.

Author Response

The manuscript has sufficiently been improved. The resolution of Figure 1 needs improvement.

Thank you. The current resolution of Figure 1 is 600dpi for a greyscale image. We known upload a 1200dpi grayscale image. We hope the resolution is now satisfactory. The quality of the figure may have been compromised due to its insertion into a Word document, which can lead to a reduction in resolution.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors address my comments well, however, the main concern regarding HdOGTT and GDM diagnosis co-occurrence was not adequately addressed as they start describing physiological mechanisms that do not pertain to the question. The authors need to include the following or similar in the methods: GDM is diagnosed based on elevated glucose levels at any OGTT time point (e.g., fasting, 1h, or 2h). In our study, women who had a glucose value <70 mg/dL at one point — most commonly fasting — often had elevated levels at subsequent time points, qualifying them for GDM. Thus, hypoglycaemia and GDM diagnosis can co-occur.

Comments on the Quality of English Language

English language still needs to be improved. For example:

"This approach was undertaken done" - double verb

"This approach was undertaken done in accordance with the recommendations of the American Diabetes Association, which defines hypoglycaemia as a blood glucose concentrations of less than 70 mg/dL (<3.9 mmol/L) and sensor glucose concentrations of less than 63 mg/dL (<3.5 mmol/L) [25]” - should be "who define", "as blood glucose concentrations"

Careful with causal language - you are looking at associations so verbiage like "more prone to X, Y, Z" is not appropriate.

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

In this revised manuscript, the authors covered all the points previously mentioned. Congratulations for their fine work. 

Author Response

In this revised manuscript, the authors covered all the points previously mentioned. Congratulations for their fine work. 

Thank you.