Important Role of Pregnancy Planning in Pregnancy Outcomes in Type 1 Diabetes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article “Important role of pregnancy planning for pregnancy outcomes 2 in type 1 diabetes” by Juza et al. describes the effects of pregnancy planning in patients with Type 1 Diabetes (T1D). The topic is of high relevance and the study was planned and conducted in a meaningful way. However, there are multiple issues that need to be addressed, as outlined below:

L50: “and it should be a part of standard diabetes care” – What does the word “it” refer to here – pregnancy planning? Please clarify.

L87: Please don’t share such many details about this one patient who was not part of the study anyway. It’s sufficient to state that the additional diagnosis “adrenal insufficiency (Addison's disease)” led to exclusion.

L90: How was the “planned pregnancy” status defined? Was this based on a questionnaire the participants had to fill in?

L90: How did you assess that they were prepared in “accordance with Diabetes Poland clinical practice recommendations”? Did you assess that by questionnaire? Please add details.

Table 2: Please add exact p-values instead of “<0.001”

L190: “However, time spent in hypoglycemia” - The sentence is cut off.

Minor:

L41: Please only introduce the abbreviation once, when it’s first mentioned in the text

Figure 2: A lot of people have issues telling the difference between red and green, could you change the colors?

There is some awkward wording in the text, maybe consider having a native speaker proofread it. It’s a minor issue, though.

Author Response

Dear Reviewer,

In my first word let me thank you on behalf of all co-authors for your valuable and insightful remarks, comments, suggestions and recommendations to our manuscript entitled “Important role of pregnancy planning for pregnancy outcomes in type 1 diabetes”. In the attachment you will find our answers to them, while in the revised manuscript you will find we corrected the text according to them.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

You have provided a useful observational research that tackles an issue that is both current and clinically significant. The results are presented in an understandable manner and are supported up by statistical analysis in a well-structured manuscript. Before publication, a few editorial, interpretive, and methodological issues need be resolved.

Major comments

1. Examine the biases and clarity of the study design: Although you acknowledge that the retrospective single-center approach has limitations, I suggest that you describe how confounding variables and selection bias were managed. Could socioeconomic position, education, or access to healthcare, for instance, have affected the likelihood of planning a pregnancy and its results?
   Think about adding a brief explanation of how these variables might have affected the outcomes and whether any effort was taken to account for them.
2. What is meant by "planned pregnancy"?
   More specificity is required in the operational definition of what is meant by a "planned pregnancy." Were there particular clinical criteria (e.g., pre-pregnancy counseling, HbA1c aim) or was it based only on patient self-reporting?
   Clearly state the methods used to document and validate pregnancy planning.
3. Sample size and statistical power: The sample size is appropriate for a single center, but the statistical power is constrained. For instance, underpowering may be the cause of the lack of substantial group variations in LGA/macrosomia.
   For important results, think about conducting and reporting a post hoc power analysis.
4. Confounding and outcome measures: When comparing planned and unexpected pregnancies, the impact of gestational weight gain and insulin dosage on fetal outcomes is recognized but not properly controlled for.
   When examining birthweight-related outcomes, use multivariable regression analysis if at all possible to account for insulin dosage, weight growth, and baseline HbA1c.
5. Novelty and literature context: By integrating planning status with CGM and CSII data, the study makes a significant contribution. However, highlighting the ways in which this cohort is different from previous studies (e.g., access to GOCCF help) could enhance the novelty.
   Give a clear explanation of how this study differs from earlier research, particularly that which has already been quoted from Poland and other nations.

Conclusion could be more forward-looking, emphasizing the implications for policy (e.g., expanding access to pre-pregnancy counseling in diabetes care).

Minor Comments

There are minor grammatical inconsistencies (e.g., “pregnancy was planned” vs. “planned pregnancy group”)—standardize across the manuscript.

The use of commas and spacing in percentages and units (e.g., “10,4%” instead of “10.4%”) should be consistent with journal style.

Table 3 and 4 are informative, but adding p-values for insulin dose and weight gain comparisons between planned and unplanned pregnancies would be helpful.

Figure 1 could benefit from including correlation coefficients in panel A.

Ethical approval is appropriately stated. It would be helpful to clarify if all personal identifiers were removed, especially for the extreme case described (pregnancy terminated at 28 weeks with neonatal death).

A few references are repeated (e.g., #18 appears earlier as #11) and the formatting is inconsistent (e.g., lack of author initials in some cases).

Recheck for duplication and unify citation formatting.

Author Response

Dear Reviewer,

In my first word let me thank you on behalf of all co-authors for your valuable and insightful remarks, comments, suggestions and recommendations to our manuscript entitled “Important role of pregnancy planning for pregnancy outcomes in type 1 diabetes”. In the attachment you will find our answers to them, while in the revised manuscript you will find we corrected the text according to them.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors of this article are writing about an important topic: how planning a pregnancy affects the health of women with type 1 diabetes (T1D). It's straightforward, well-organized, and gives us useful real-world information. It's especially important to talk about current tools like insulin pumps and continuous glucose monitors (CGMs) right now. That being said, there are a few places where the paper could be longer to make its case even better.

The main point is very clear: planning a pregnancy helps control blood sugar better and lowers the risk of premature birth, which is in accordance with current standards. The tables and figures that go with the data are well done and make a strong case.
1. However, some outcomes (such birth abnormalities) were too rare to make strong judgments with fewer than 100 women. It might help to do a broader study or combine data from several centers.
2. Parameters like money, education, or how supportive families were weren't included. These could have an impact on whether women planned their pregnancies or had favorable outcomes, therefore it would be helpful to mention them.
3. The manuscript says that women were trained on pumps and CGMs, but it doesn't say how this training was done. It would be helpful for others to know what training was like in a few words.
4. Surprisingly, planned pregnancies didn't lead to fewer big kids (macrosomia), even if they had greater control over their blood sugar. The writers should look into why this happened. Did weight increase or insulin resistance have something to do with it? Or is there something else to blame for that?
5. Because the study was done at only one center, the results may not be true everywhere. If the authors were honest about this constraint from the start, the paper would feel more balanced.
6. Maybe the authors should offer specific measures to urge more women to plan their pregnancies, such as greater talks between doctors and patients and educational initiatives.
This is a good paper that gives useful information, especially for clinics who use diabetes technology. It would be much better if it explained the "why" behind surprising results and made its limitations explicit. It would be ready for publication if you thought about the details a little more.

Author Response

Dear Reviewer,

In my first word let me thank you on behalf of all co-authors for your valuable and insightful remarks, comments, suggestions and recommendations to our manuscript entitled “Important role of pregnancy planning for pregnancy outcomes in type 1 diabetes”. In the attachment you will find our answers to them, while in the revised manuscript you will find we corrected the text according to them. You will find our reply in the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have properly addressed all my concerns and comments. Thank you so much!