Reviewer ’s report  
 
Title: Do self -reported pregnancy complications add to risk evaluation in older women with 
established cardiovascular disease?  
 
Version: 0 Date: 26 Jul 2019  
 
Reviewer: Morounfolu Thompson  
 
Reviewer's report:  
 
Originality  
Although not  a uniquely original, topic, this is an interesting study and may have some 
contribution to the current medical knowledge available on this topic.  
The authors may wish to read this review in supporting their study justification - Hauspurg A, 
Ying W, Hubel  CA, Michos ED, Ouyang P. Adverse pregnancy outcomes and future maternal 
cardiovascular disease. Clinical cardiology. 2018 Feb;41(2):239 -46. 
What the authors may contribute though is in terms of risk in older women with already 
established cardiovascular d isease, and their raising the question of a possible link with 
antepartum haemorrhage. The authors may therefore also wish to reflect this in their study title 
by adding the word "older" e.g. Do self -reported pregnancy complications add to risk evaluation 
in older women with established cardiovascular disease.  
 
Abstract  
A couple of adjustments need to be made in this section - a more concise inclusion of the main 
study objective and the statement in the conclusion that suggests a statistically significant 
conclusion "The mean age was 67.5 (SD 9.5) years. GHT and/or PE tended to be more common 
in women with CVD than in women without (20.3% vs 10.8%, p=0.066)" should explicitly state 
the lack of a statistical correlation.  
 
Introduction and Background  
A retros pective questionnaire study investigating a possible link between a previous history of 
pregnancy complications in menopausal women with or without established cardiovascular 
disease.  
It is unclear whether this was with a view to improving risk assessment in women with already 
established cardiovascular disease (CVD) or assisting in screening for this. Whatever the case, 
this is not clearly presented to the reader and description of the study objectives should be 
consistent throughout the manuscript. Cleare r details are needed in the background section.  
It would appear that the authors focused on trying to establish a relationship between multi -
systemic cardiovascular disease after the menopause and utero -placental complications in 
pregnancy. Based on report s of possibly shared pathophysiological mechanisms in terms of 
vascular function, immunoregulation and metabolic control. On these grounds, the second and 
third aims need to be better explained in the background section with clearer justification for the 
study (Page 4, Lines 1 -10). The abstract should be re -written with these in mind.  
 
Methodology  
The data is somewhat confusingly derived from a questionnaire study conducted among post -
menopausal women obtained from a composite of three different cohort stu dies. This is a  
considered limitation when compared to other similarly retrospective studies in the medical 
literature that draw direct data from large patient databases. There are however a few published 
studies with similar numbers.  
The pregnancy compl ications sought examined included previous miscarriage, subfertility, 
gestational hypertension (GHT), preeclampsia (PE), low birth weight, preterm birth, bleeding in 
late pregnancy, gestational diabetes mellitus and high birth weight.  
 
The clinical investi gation of the three arterial beds was comprehensive, and is well described by 
the authors, showing a high investigation uptake rate in their population. It is not stated and 
unclear whether or not the questionnaire employed in this study based on reference  #23 (Jacobs 
and Hubel) is validated. The statistical analyses are only described briefly and this section 
because of its importance requires more detail. A couple of descriptive flow charts may be 
helpful and the predictive statistics basis explained, alt hough this should be subject to the 
Statistician's review.  
 
There are a couple of typographical errors  
P4 Line 10 Predict not predicate  
P8 Line46 - Supplement not supplementary  
P11 Line 56 - Expected not expectable  
P11 Lines 15 -18 belongs to the introduct ion/background where it would make a significant 
difference in helping the reader to understand why the study was conducted in the first place.  
 
There is an excellent discussion of the study limitations, and some of these statements again e.g. 
P11 Lines 43 -51 would perhaps be more helpful if included in the background section discussing 
study justification.  
Nonetheless, no clear relationship could be demonstrated between the self -reported pregnancy 
complications and established cardiovascular disease as stated by the authors, however, any 
conclusions to be drawn may be limited by the nature of the study and study size. This should be 
stated in concl uding discussion as done on P10 Lines 47 -50. 
Are the methods appropriate and well d escribed?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusion s drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
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3. Do you hold or are you currently applying for any patents relating to the content of the 
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4. Have you received reimbursements, fees, funding, or salary from an organization that 
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5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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below. If your r eply is yes to any, please give details below.  
 
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