Profile of congenital heart disease in infants born following exposure to preeclampsia.

BACKGROUND: Events in pregnancy play an important role in predisposing the newborn to the risk of developing CHD. This study evaluated the association between maternal preeclampsia and her offspring risk of CHD.
METHODS: This is a cohort study of 90 sex-matched neonates (45 each born to women with preeclampsia and normal pregnancy) in Jos, Nigeria. Anthropometry was taken shortly after delivery using standard protocols. Echocardiography was performed within 24 hours of life and repeated 7 and 28 days later. SPSS version 25 was used in all analyses. Statistical significance was set at p<0.05.
RESULTS: Congenital heart disease (CHD) was observed in 27 (30.0%) of newborns of women with preeclampsia compared with 11 (12.1%) of newborns without preeclampsia (p<0.001) at the end of 7 days and in 19 (21.1%) of newborns of women with preeclampsia and 3 (3.3%) of newborns of women without preeclampsia by the end of the 4th week of life (p<0.001). Overall, ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions found among all the newborns studied in the first week of life. Isolated atrial and ventricular septal defects were seen in 4 (4.4%) of the newborns of women with preeclampsia. Being the infant of a woman with preeclampsia was associated with about 8-fold increased risk of having CHD (OR = 7.9, 95% CI = 2.5-24.9, p<0.001).
CONCLUSION: CHD may be more common in newborns of women with preeclampsia underscoring the need for fetal and newborn screening for CHD in women with preeclampsia so as to improve their infant's well being.

Introduction

Preeclampsia/eclampsia (PE/E) has remained a significant public health problem in Nigeria and the developing world. It is said to complicate an estimated 2–10% of all pregnancies resulting in five-fold increase in perinatal morbidity and mortality.[1,2] The pathophysiology of PE/E entails generalized endothelial dysfunction initiated by abnormal placentation. This endothelial dysfunction is associated with different degrees of fetal injury even though perinatal outcome is also influenced by gestational age and severity of the hypertension.[3,4] Preeclampsia is thought to result from disturbed placental function in early pregnancy possibly due to failed interaction between two genetically different organisms. [4,5] As early as 12 weeks gestation, placental flow defects have been shown to occur in women who subsequently develop pre-eclampsia. This placental dysfunction causes flow defect and hypoxia episodes with resultant generation of reactive oxygen species, placental oxidative stress and increased serum fms-like tyrosine kinase 1(sFlt-1)production similar to what is seen in human fetuses with congental heart diseases. [4,5] The hypoxia induced overproduction of sFlt-1 could activate a cycle wherein high sFlt-1 levels inhibit angiogenesis and exacerbate the placental hypoxia, which subsequently causes an increase in placental sFlt-1 production.[4,5] Considering this similarity in pathogenesis, it is possible that angiogenic imbalance may play an important role in the pathogenesis of CHD especially in infants of women with preeclampsia.[3,5]

Congenital heart diseases (CHD) are the most common birth defects globally.[6,7] They are also important cause of morbidity and mortality globally.[8,9] Current estimates by the Centers for Disease Control and Prevention (CDC) in the US report CHD as responsible for about 4.2% of all neonatal deaths with most occurring in the first 28 days of life. Apart from genetic (e.g. trisomies), infectious (e.g. TORCHES), drugs, alcohol and environmental factors, febrile illness and inflammation have also been shown to predispose infants to CHD.[10]

Preeclampsia is associated with poor infant outcomes especially low birth weight and prematurity.[11] Being an inflammatory disorder, preeclampsia itself may predispose infants to congenital anomalies including CHD.[11,12] It is thus relevant to investigate the possible association between CHD and preeclampsia. We therefore sought to characterize the spectrum and burden of CHD in infants born following preeclampsia and also to determine whether preeclampsia is associated with CHD.

Materials and methods

Study setting

We conducted this study in the 4 tertiary health facilities in Jos namely; Jos University Teaching Hospital (JUTH), Plateau Specialist Hospital (PSSH), Bingham University Teaching Hospital (BhUTH) and Our Lady of Apostle (OLA) Hospital. Each of these hospitals has specialist obstetric care services. Altogether, they have an annual delivery rate of about 14,000 babies with preeclampsia/eclampsia accounting for about 5% of the deliveries annually.

Study population

This study was carried out between April 2017 and May 2018 as part of the infant outcomes study on women with preeclampsia in Jos. All the women were recruited antenatally and followed up to delivery. At delivery, all the infants had anthropometry and echocardiography done. We identified 45 newborns from women with preeclampsia at birth in the delivery room and matched them for sex with 45 newborns of women with normal pregnancy. We used OpenEpi version 3.03a to determine a minimum sample size of 80 (40 neonates in each arm) based on the estimated effect size of 20%, a power of 80% and an α level of 0.05.[13] We excluded newborns of women with other chronic disorders like diabetes, HIV and Sickle cell anemia in the control and exposure groups in order to avoid confounding. Ethical approval was obtained from each of the participating hospitals before commencement of the study. Written informed consent was obtained from the mothers before recruiting the newborns.

Preeclampsia was defined as systolic blood pressure ≥140 mmHg or diastolic pressure ≥90 mmHg (or increases of 30 mmHg systolic or 15 mmHg diastolic from the baseline) on at least two occasions, six or more hours apart and associated proteinuria that develops from the 20th gestational week in a previously normotensive woman.

Study design

This study was a cohort design that compared the spectrum of CHD in newborns of women with preeclampsia versus those with normal pregnancy in the four tertiary care centers in Jos Nigeria.

Study procedure

Each newborn had a transthoracic echocardiography done at least 4 hours post-delivery in the nursery to assess for the presence of CHD. This was repeated for all the infants at 7 days and 28 days of life in order to exclude physiologic patent ductus arteriosus and foramen ovale. All measurements were performed according to American Society of Echocardiography guidelines by an experienced Paediatric Cardiologist.[14] Echocardiography was done following a standard examination protocol using a Vivid e ultrasound machine (General Electric, USA) equipped with a P6 Phased Array ultrasound transducer.[14] Anthropometric measurements were done by weighing each naked newborn to the nearest 50g using a way master bassinet weighing scale operated by a trained midwife. [15,16]

Ethical considerations

The institutional review board of the Jos University Teaching Hospital reviewed and approved the study (JUTH/DCS/ADM/127/XIX/6632).

Each infant was identified with a code that does not contain their name. Only the principal investigator has access to the database linking the name of the individual with the code. All material data including the study forms and specimen bottles were labeled accordingly with the printed unique identification numbers. Different biological fluids (i.e. serum and plasma specimen) were marked with different prefixes for ease of identification.

Statistical analysis

Statistical analysis was done using SPSS version 25.[17] Mean differences in maternal age, booking weight and parity as well as infant weight and gestational age were compared between babies born following preeclamptic pregnancy and those born following normal pregnancy using a t-test. Difference in proportion of the newborns by sex as well as maternal education, fever in pregnancy, alcohol use and contraceptive use was done using 2 by 2 table cross tabulations. Spectrum of CHD was depicted using bar charts and a frequency table. Univariate analysis was done to evaluate the relationship of each of the maternal and infant variables with CHD. Those that were found to be significant were then included in Multivariable logistic regression analysis to assess the relationship between CHD and these maternal and infant characteristics. The criterion for significance for all analyses was set at a P-value of < 0.05.

Results

Descriptive characteristics

Table 1 shows maternal and infant descriptive characteristics. There were 25 (55.6%) male newborns and 20 (44.4%) female newborns delivered to both women with preeclampsia and those with normal pregnancy. The newborns of women with preeclampsia were significantly lighter compared with the newborns of women with normal pregnancy (mean birth weight 2529.5±817.5 vs 3079.2±527.4 grams; p<0.001) and of younger gestational age (36.8 ± 3.2 vs 38.7±2.0 weeks; p = 0.001). Women with preeclampsia were significantly heavier compared with women without preeclampsia (mean weight at booking of 73.9±19.0 kg vs 64.5±14.0 kg; p = 0.02, mean BMI at booking 46.3±11.6 vs 40.1±8.3, p = 0.009)), but not significantly older (31.1± 6.3 vs 29.3±5.6 years; p = 0.17). Mean maternal parity was not significantly different between the two groups (preeclampsia = 2.9±2.0 vs normal pregnancy = 2.9±2.2, p = 0.99), whereas fever in pregnancy was significantly more common in the preeclampsia group compared to women with normal pregnancy (11[12.2%] vs 8[8.9%]; p<0.001).

Table 1

Baseline demographics and clinical characteristics of the study population (N = 90).

Variable	Preeclampsia (n = 45)	Normal Pregnancy (n = 45)	t	p
Mean Age (years)	31.1±6.3	29.3±5.6	1.40	0.17
Mean Booking weight (kg)	73.9±19.0	64.5±14.0	2.50	0.02
Mean Maternal BMI(Kg/m2)	46.3±11.6	40.1±8.3	2.69	0.009
Mean Parity	2.9±2.0	2.9±2.2	0.02	0.99
Maternal Education
At least Primary School	11(24.4%)	7(15.6%)	1.24	0.57σ
Secondary School	13(28.8%)	13(28.8%)
Beyond Secondary School	21(46.6%)	25(55.6%)
Fever in Pregnancy	11(24.4%)	8(17.8%)	23.64	<0.001σ
Infant Sex
Male	25(55.6%)	25(55.6%)	3.34	0.18σ
Female	20(44.4%)	20(44.4%)
Mean Birth Weight (grams)	2529.5±817.5	3079.2±527.4	3.79	<0.001
Mean Gestational Age (weeks)	36.8±3.2	38.7±2.0	3.35	0.001

σ = Chi square statistics, significant values are in italics

Because fewer than 5 women per group reported alcohol and cigarette intake, we excluded those variables from the analysis.

Prevalence and spectrum of congenital heart disease (CHD)

As shown in Fig 1A & 1B and Table 2, by day 7, CHD was observed in 27 (60.0%) of newborns of women with preeclampsia compared with 11(22.2%) of newborns of women with normal pregnancy (p<0.001). By day 28 of life, 19 (42.2%) of newborns of women with preeclampsia had CHD, while 3 (6.6%) of newborns of women with normal pregnancy had CHD.

Fig 1

(A) Distribution of Congenital Heart Disease (CHD) in newborns by preeclampsia exposure status at the end of day 7. (B) Distribution of Congenital Heart Disease (CHD) in newborns by preeclampsia exposure status at the end of day 28.

Table 2

Frequency of occurrence of type of congenital heart disease (CHD) in the study population (N = 90) by exposure status.

	Day 7		Day 28
Variable	Preeclampsia n = 45	Normal pregnancy n = 45	Preeclampsia n = 45	Normal pregnancy n = 45
ASD	4(8.8%)	0(0.0%)	4(8.8%)	0(0.0%)
Isolated	2(4.4%)	0(0.0%)	2(4.4%)	0(0.0%)
With PDA	2(4.4%)	0(0.0%)	2(4.4%)	0(0.0%)
PDA	13(28.8%)	8(17.8%)	4(8.8%)	1(2.2%)
Isolated	8(17.8%)	7(7.8%)	2(2.2%)	1(1.1%)
With PFO	3(6.6%)	1(2.2%)	0(0.0%)	0(0.0%)
With ASD	2(4.4%)	0(0.0%)	2(2.2%)	0(0.0%)
PFO	11(24.4%)	3(6.6%)	11(24.4%)	2(4.4%)
VSD	2(4.4%)	0(0.0%)	2(4.4%)	0(0)
*Total	27(60.0%)	10(22.2%)	19(42.2%)	3(6.6%)

*due to 2 patients having a combination of lesions, the frequency does not sum.

Atrial septal defect (ASD), patent ductus arteriosus (PDA), patent foramen ovale (PFO) and ventricular septal defects (VSD) were the prevalent CHD types observed which persisted beyond the first week of life. Isolated ASD and VSD were observed only in newborns born to women with preeclampsia (Table 2). The PDA in newborn of normal pregnancy and 8 (8.9%) of those newborns of preeclamptic women had closed by the 28th day of life (Table 2).

Gestational age distribution by CHD status

In Fig 2, CHD is seen mainly among newborns with gestational age between 35–40 weeks. The gestational age distribution of those newborns with CHD is similar to that of newborns without CHD.

Fig 2

Distribution of gestational age by CHD status.

Factors associated with congenital heart disease (CHD)

Table 3 shows logistic regression coefficients of variables associated with CHD. Being the infant of a woman with preeclampsia was associated with an 8-fold increased likelihood of having CHD (OR = 7.9, 95%CI = 2.5–24.9, p<0.001). Being a female infant or being preterm was associated with an increased likelihood of having CHD of 1.8 times (OR = 1.8, 95%CI = 0.63–4.9, p = 0.29) and 1.4 times (95% CI = 0.22–9.3, p = 0.70) respectively though not statistically significant.

Table 3

Logistic regression estimates of the relationship between some study variables and congenital heart disease (CHD).

						95% CI
Variables	B	SE	Wald	p value	Exp(B)	Lower	Upper
Birth weight	.00	.001	.424	.52	1.0	1.0	1.0
Miscarriages	.28	.299	.892	.33	1.3	0.7	2.4
Preeclampsia	2.06	.586	12.437	< .001	7.9	2.5	24.9
Maternal age(yr)	-.03	.045	.556	.456	.97	.89	1.1
Gestational age	.10	.144	.563	.45	1.1	.84	1.5
Female infant	.56	.523	1.145	.29	1.8	.63	4.9
Prematurity	.36	.953	.142	.70	1.4	.22	9.3

CI = Confidence interval, SE = Standard error

Discussion

We found a significantly higher proportion of newborns born to women with preeclampsia having CHD compared to those born to women with normal pregnancy. Shunt lesions such as isolated ASD and VSD were predominantly seen in newborns of women with preeclampsia. Patent ductus arteriosus and PFO were isolated in both groups of newborns. This is similar to what Auger and colleagues[18] reported in an analysis of hospital discharge records in Quebec Canada, where a high prevalence of CHD was observed in women with preeclampsia compared with normal pregnancy. Similar to our findings, Auger reported a high proportion of shunt lesions like ventricular septal defects as the most common CHD isolated. [18]

Though prematurity is associated with a higher prevalence of CHD globally, our study did not find a significant association between prematurity and the odds of having CHD.[19] This may be due to the fact that PDA, a common CHD in premature infants was only considered in the diagnosis after the 4th week of life so as to exclude those PDA that may be as a result of delayed closure of the ductus arteriosus in premature infants. [19,20] In addition, we did not find any significant association between gender and the risk of having CHD similar to global reports.[20,21]

We found a nearly 8-fold increased risk of CHD in the newborns of women with preeclampsia. Current reports suggest an association between preeclampsia and the heightened risk of CHD in fetuses. In a study of a cohort of 700,000 Danish women, Boyd et al.[21] reported that early preeclampsia was associated with a 6-fold increased CHD risk in offspring. In addition, pregnant women whose fetuses have been shown to have CHD in utero have been shown to have a nearly 7-fold increased risk of developing preeclampsia, regardless of the nature of the CHD.[21] The increased risk for developing CHD in fetuses of women with preeclampsia has been attributed to the likelihood of shared angiogenic imbalance between the mother and fetus.[21-23] Since studies have shown a causal relationship between angiogenic imbalance and occurrence of developmental defects of the human fetal heart, it is thus not surprising finding an increased risk of CHD in the newborns of the women with preeclampsia in our study.[22,23]

Clinical significance of our study results

With the advent of echocardiography and the development of fetal and newborn screening protocols, early and timely diagnosis of CHD is possible and has improved not just the management of these newborns but also their survival.[24,25] The association between preeclampsia and CHD may suggest that clinicians managing women with preeclampsia in addition to other fetal surveillance screening, consider including the screening for congenital heart diseases in order to improve the early diagnosis and management of these newborns who may have CHD. This will help improve the survival of the infants of women with preeclampsia.[18,24,25]

Strengths of our study results

Strengths of our study results include the cohort design of the study, the collaborative efforts between obstetricians and paediatricians, and the use of standard definitions and protocols for the classification and diagnosis of CHD and preeclampsia. In addition, the inclusion of a 28 day follow up on the newborns allowed us to exclude those lesions such as patent ductus arteriosus and patent foramen ovale, which are transiently present at birth as a result of physiologic changes in newborns.

Limitations of our findings

The small sample size, while appropriately powered for a pilot study and producing statistically significant results, is a limitation of the present study. In addition, we did not include abortuses and stillborns delivered in the study because of the inability to perform fetal and neonatal autopsy. The exclusion of CHD from these sources (abortuses, still births) may have affected the potential relationship between preeclampsia and CHD reported here. A large population based study incorporating pathological examination of stillborns and abortuses would thus be needed to validate our findings.

Conclusions

Congenital heart diseases may be more common in newborns of women with preeclampsia. This underscores the need for fetal and newborn screening for congenital heart defects as part of the fetal and newborn surveillance studies in women with preeclampsia so as to improve their infant’s well being.

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14 Jan 2020

PONE-D-19-30623

PROFILE OF CONGENITAL HEART DISEASE IN INFANTS BORN FOLLOWING EXPOSURE TO PREECLAMPSIA

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Reviewer #1: In this study, authors collected 90 sex-matched neonates to evaluate the coherence of related clinical parameters and found that maternal preeclampsia is closely related with the offspring risk of CHD. Actually, this is not the first time to investigate those two factors’ relationship. Former scholars also got the same conclusion. For this study, I think there are some problems need to be resolved:

1. Table 2, in preeclampsia group, the total number of PDA is 4, however if you counted the sum of three category (isolated, with PFO and ASD), the number is just 2 (just in with ASD). What is the problem? Is there a mistake?

2. In the discussion, authors said,” Though prematurity is associated with a higher prevalence of CHD globally, our study did not find a significant association between prematurity and the odds of having CHD.” How can they get this opinion? Because in table 1 we can see that mean gestational age of women with preeclampsia or normal pregnancy is significantly different. Neonates whose mother with preeclampsia are premature and have a high risk of CHD. So, I think authors cannot give this conclusion.

3. As the design of this study, have all the mothers been excluded the genetic disease of heart, have they all detected the TORCHES. How about the history of delivery? Will it affect the health of newborns? Like the age of the first pregnancy and times of pregnancy and delivery.

Reviewer #2: Reviewer Notes (also attached as PDF)

PROFILE OF CONGENITAL HEART DISEASE IN INFANTS BORN FOLLOWING EXPOSURE TO PREECLAMPSIA

Summary:

This cohort study investigated the association between CHD in offspring of women with PE/E. They took into account for newborn sex, gestational age, and maternal factors (weight, age, and education). They reported that newborns from PE/E pregnancies were associated with an approximate 8 fold increase in risk for CHD. Most common of these defects included ASD, PFO, VSD, and PDA. Most of the PDA cases were resolved by the evaluation at day 28. These findings of this report is consistent with findings from other reports in observing increased CHD and decreased birth weight associated with PE/E pregnancies. However, this study re-evaluates the prevalence of PDA in infants from PE/E pregnancies. This study is unique in that it conducts a day 28 evaluation for CHD, therefore, accounting for PDA and PFO that may be transiently present in preterm infants. Overall, this paper provides statistical information about the association between PE/E pregnancies and increased CHD risk, and provides grounds for urging CHD screening for fetuses and newborns from PE/E pregnancies. Reviewers concerns are mentioned below with specific sections. The grammar throughout the paper needs to be reviewed with care.

Major Concerns:

In the abstract results section, you mention, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions in the first week of life”. The group (PE/E) to which this is referring to needs clarification.

In the abstract results section, you mention, “Being the infant of a woman with preeclampsia was associated with about 8-fold increased risk of having CHD (OR=7.9, 95%CI=2.5-24.9)”. If the p-value is mentioned it would provide more information about statistical significance.

In the introduction, you mentioned that one of the reasons to look into the association between CHD and PE/E is because PE/E itself entails an inflammatory state. However, before this statement is given, the etiology is not given. The reasoning could be more cohesive if a statement or two about PE/E and inflammation is provided in the first paragraph of this section.

In the results section, you mention “All of the PDA in newborns of normal pregnancy and 8 (8.9%) of those newborns of preeclamptic women had closed by the 28th day of life (Table 2)”. Table 2 shows that there are still 4 newborns (from PE/E) and 1 newborn (from normal pregnancy) with PDA. I believe it would be more accurate to say “most of the PDA cases” instead of “all”.

In the results section, you mention, “Being the infant of a woman with preeclampsia was associated with an ~8-fold increased likelihood of having CHD (OR=7.9, 95%CI=2.5-24.9). Being a female infant or being preterm was associated with an increased likelihood of having CHD of 1.8 times (OR=1.8, 95%CI=0.63-4.9) and 1.4 times (95% CI= 0.22-9.3) times respectively though not statistically significant”. Including actual p-values when describing the statistics would backup your statement.

In the discussion section, you mention, “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. What is the dose referring to? What is currently mentioned does not match the other statements or logic.

Minor Concerns:

Grammar errors throughout the paper. Please double check on the adverbs, verb tenses, subject verb agreement, conjunction usage, comma usage (often missing), and subject association.

Were the maternal nutritional status during pregnancy accounted for? Maternal nutrient status of various vitamins and minerals have a profound effect on fetal development.

It might be more informative to report the maternal weight in the form of BMI to account for their height.

PLOS One Questions:

What are the main claims of the paper and how significant are they for the discipline? Answer: Mentioned is summary (above).

Are the claims properly placed in the context of the previous literature? Have the authors treated the literature fairly? Answer: The connection between inflammation and PE/E in the introduction section needs to be elaborated. This study could prompt further investigation on the link between PE/E and CHD if the authors elaborate on potential mechanisms of angiogenic imbalance that leads to CHD development.

Do the data and analyses fully support the claims? If not, what other evidence is required? Answer: Yes, all of their claims are based on observed results and statistics.

PLOS ONE encourages authors to publish detailed protocols and algorithms as supporting information online. Do any particular methods used in the manuscript warrant such treatment? If a protocol is already provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred? Answer: They utilized standardized diagnostic protocols for CHD. Statistical analysis methods are also provided.

If the paper is considered unsuitable for publication in its present form, does the study itself show sufficient potential that the authors should be encouraged to resubmit a revised version? Answer: This report needs major grammar editing before final submission.

Are original data deposited in appropriate repositories and accession/version numbers provided for genes, proteins, mutants, diseases, etc.? Answer: The author declares that all data collected from the study is made available to the public.

Are details of the methodology sufficient to allow the experiments to be reproduced? Answer: Yes, sufficient methods are provided.

Is the manuscript well organized and written clearly enough to be accessible to non-specialists? Answer: Yes, very clear organization. However, needs major grammar editing for smooth reading.

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Reviewer #1: No

Reviewer #2: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviewer Notes.pdf

Click here for additional data file.

29 Jan 2020

Reviewer number 1

1. Table 2, in preeclampsia group, the total number of PDA is 4, however if you counted the sum of three category (isolated, with PFO and ASD), the number is just 2 (just in with ASD). What is the problem? Is there a mistake?

Response:

The total number of PDA is 4 (2 with isolated lesions, 2 associated with ASD). It was a clerical error.

2. In the discussion, authors said,” Though prematurity is associated with a higher prevalence of CHD globally, our study did not find a significant association between prematurity and the odds of having CHD.” How can they get this opinion? Because in table 1 we can see that mean gestational age of women with preeclampsia or normal pregnancy is significantly different. Neonates whose mother with preeclampsia are premature and have a high risk of CHD. So, I think authors cannot give this conclusion.

Response:

Even though women with Preeclampsia have a significantly lower gestational age, our results in Table 3 showed no significant association between prematurity and risk of CHD. This is why we made the statement above.

3. As the design of this study, have all the mothers been excluded the genetic disease of heart, have they all detected the TORCHES. How about the history of delivery? Will it affect the health of newborns? Like the age of the first pregnancy and times of pregnancy and delivery.

Response:

None of the women had a clinical history of TORCHES. However, because of the peculiarity of our developing economy, pregnant women do not have genetic studies done routinely. In addition, the scope of our study did not include genetic study. Timing of delivery, mode of delivery and parity of the women was not significantly associated nor did it differ between the two cohorts. But we will in future look in that direction.

Reviewer 2

Major Concerns:

1. In the abstract results section, you mention, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions in the first week of life”. The group (PE/E) to which this is referring to needs clarification.

Response:

This statement makes reference to the overall spectrum of CHD in the total population and not in women with Preeclampsia. The statement about PE/E ends with the previous sentence.

2. In the abstract results section, you mention, “Being the infant of a woman with preeclampsia was associated with about 8-fold increased risk of having CHD (OR=7.9, 95%CI=2.5-24.9)”. If the p-value is mentioned it would provide more information about statistical significance.

Response:

Noted and corrected

3. In the introduction, you mentioned that one of the reasons to look into the association between CHD and PE/E is because PE/E itself entails an inflammatory state. However, before this statement is given, the etiology is not given. The reasoning could be more cohesive if a statement or two about PE/E and inflammation is provided in the first paragraph of this section.

Response:

Noted and corrected.

4. In the results section, you mention “All of the PDA in newborns of normal pregnancy and 8 (8.9%) of those newborns of preeclamptic women had closed by the 28th day of life (Table 2)”. Table 2 shows that there are still 4 newborns (from PE/E) and 1 newborn (from normal pregnancy) with PDA. I believe it would be more accurate to say “most of the PDA cases” instead of “all”.

Response:

Noted and corrected to read “The PDA in newborn….”

5. In the results section, you mention, “Being the infant of a woman with preeclampsia was associated with an ~8-fold increased likelihood of having CHD (OR=7.9, 95%CI=2.5-24.9). Being a female infant or being preterm was associated with an increased likelihood of having CHD of 1.8 times (OR=1.8, 95%CI=0.63-4.9) and 1.4 times (95% CI= 0.22-9.3) times respectively though not statistically significant”. Including actual p-values when describing the statistics would backup your statement.

Response:

Noted and corrected.

In the discussion section, you mention, “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. What is the dose referring to? What is currently mentioned does not match the other statements or logic.

Response:

The statement is hereby deleted.

Minor Concerns:

1. Grammar errors throughout the paper. Please double check on the adverbs, verb tenses, subject verb agreement, conjunction usage, comma usage (often missing), and subject association.

Response:

Noted with thanks. Will correct that.

2. Were the maternal nutritional status during pregnancy accounted for? Maternal nutrient status of various vitamins and minerals have a profound effect on fetal development.

It might be more informative to report the maternal weight in the form of BMI to account for their height.

Response:

Maternal nutritional status assay of vitamins and other nutrients was not done.

Once again, we appreciate the opportunity given to us to submit our manuscript. We also appreciate the great work done by the reviewers in reviewing our manuscript.

Submitted filename: Response_Reviewers.doc

Click here for additional data file.

14 Feb 2020

PONE-D-19-30623R1

PROFILE OF CONGENITAL HEART DISEASE IN INFANTS BORN FOLLOWING EXPOSURE TO PREECLAMPSIA

PLOS ONE

Dear Dr. Yilgwan,

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Linglin Xie

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: Reviewer 2 - this section also attached as word doc.

Major Concerns:

1. In the abstract results section, you mention, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions in the first week of life”. The group (PE/E) to which this is referring to needs clarification.

a. Response: This statement makes reference to the overall spectrum of CHD in the total population and not in women with Preeclampsia. The statement about PE/E ends with the previous sentence.

2nd Review: I understand now. But may be helpful to clarify by saying, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions among newborns of women without preeclampsia in the first week of life.”

2. In the abstract results section, you mention, “Being the infant of a woman with preeclampsia was associated with about 8-fold increased risk of having CHD (OR=7.9, 95%CI=2.5-24.9)”. If the p-value is mentioned it would provide more information about statistical significance.

a. Response: Noted and corrected

2nd Review: Verified.

3. In the introduction, you mentioned that one of the reasons to look into the association between CHD and PE/E is because PE/E itself entails an inflammatory state. However, before this statement is given, the etiology is not given. The reasoning could be more cohesive if a statement or two about PE/E and inflammation is provided in the first paragraph of this section.

a. Response: Noted and corrected.

2nd Review: Verified. I think the current version provides a very detailed background and justification for the study.

4. In the results section, you mention “All of the PDA in newborns of normal pregnancy and 8 (8.9%) of those newborns of preeclamptic women had closed by the 28th day of life (Table 2)”. Table 2 shows that there are still 4 newborns (from PE/E) and 1 newborn (from normal pregnancy) with PDA. I believe it would be more accurate to say “most of the PDA cases” instead of “all”.

a. Response: Noted and corrected to read “The PDA in newborn….”

2nd Review: Verified.

5. In the results section, you mention, “Being the infant of a woman with preeclampsia was associated with an ~8-fold increased likelihood of having CHD (OR=7.9, 95%CI=2.5-24.9). Being a female infant or being preterm was associated with an increased likelihood of having CHD of 1.8 times (OR=1.8, 95%CI=0.63-4.9) and 1.4 times (95% CI= 0.22-9.3) times respectively though not statistically significant”. Including actual p-values when describing the statistics would backup your statement.

a. Response: Noted and corrected.

2nd Review: Verified.

6. In the discussion section, you mention, “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. What is the dose referring to? What is currently mentioned does not match the other statements or logic.

a. Response: The statement is hereby deleted.

2nd Review: This statement is still there. What do you mean by dose? “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. The sentence after that also seems to not flow well right after this statement. The statement itself sounds a little redundant. Can you make the last few sentences of this paragraph more concise?

Minor Concerns:

1. Grammar errors throughout the paper. Please double check on the adverbs, verb tenses, subject verb agreement, conjunction usage, comma usage (often missing), and subject association.

a. Response: Noted with thanks. Will correct that.

2nd Review: Did not notice any major grammar issues.

2. Were the maternal nutritional status during pregnancy accounted for? Maternal nutrient status of various vitamins and minerals have a profound effect on fetal development. It might be more informative to report the maternal weight in the form of BMI to account for their height.

a. Response: Maternal nutritional status assay of vitamins and other nutrients was not done. Once again, we appreciate the opportunity given to us to submit our manuscript. We also appreciate the great work done by the reviewers in reviewing our manuscript.

2nd Review: Reporting the weight status of the mothers could be more informative if the weight was reported as BMI if available.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviewer 2. Second Review.docx

Click here for additional data file.

17 Feb 2020

Reviewer 2

Major Concerns:

1. In the abstract results section, you mention, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions in the first week of life”. The group (PE/E) to which this is referring to needs clarification.

2nd Review: I understand now. But may be helpful to clarify by saying, “ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions among newborns of women without preeclampsia in the first week of life.”

Second review response:

Corrected to read; Overall, ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions found among all the newborns studied in the first week of life.

2. In the discussion section, you mention, “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. What is the dose referring to? What is currently mentioned does not match the other statements or logic.

a. Response: The statement is hereby deleted.

2nd Review: This statement is still there. What do you mean by dose? “This risk is dose dependent and likely due to a shared angiogenic imbalance in the mother and fetus.20-22”. The sentence after that also seems to not flow well right after this statement. The statement itself sounds a little redundant. Can you make the last few sentences of this paragraph more concise?

Second review answer:

Sentence rephrased.

Minor Concerns:

1. Were the maternal nutritional status during pregnancy accounted for? Maternal nutrient status of various vitamins and minerals have a profound effect on fetal development. It might be more informative to report the maternal weight in the form of BMI to account for their height.

a. Response: Maternal nutritional status assay of vitamins and other nutrients was not done. Once again, we appreciate the opportunity given to us to submit our manuscript. We also appreciate the great work done by the reviewers in reviewing our manuscript.

2nd Review: Reporting the weight status of the mothers could be more informative if the weight was reported as BMI if available.

Response:

Done

Submitted filename: Response_Reviewers.doc

Click here for additional data file.

20 Feb 2020

PROFILE OF CONGENITAL HEART DISEASE IN INFANTS BORN FOLLOWING EXPOSURE TO PREECLAMPSIA

PONE-D-19-30623R2

Dear Dr. Yilgwan,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Linglin Xie

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

2 Mar 2020

PONE-D-19-30623R2

PROFILE OF CONGENITAL HEART DISEASE IN INFANTS BORN FOLLOWING EXPOSURE TO PREECLAMPSIA

Dear Dr. Yilgwan:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE.

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on behalf of

Dr. Linglin Xie

Academic Editor

PLOS ONE