Concealed Placental Abruption Complicating Hypertensive Disorders of Pregnancy: Exploring the Role of Point-of-Care Ultrasound

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

General: This paper is important because it describes the utility of POCUS in diagnosing concealed placental abruption, which can be a deadly and dangerous complication of pregnancy. This diagnosis is emergent and requires c-section in patients with pre-eclampsia and high blood pressure. The authors present two cases with clear image examples of concealed PA so that physicians can practice recognizing this pathology and in what types of patient presentation cases.

Title is appropriate and clear

Abstract: States the background and main findings of two patient cases of concealed placental abruption using POCUS in pregnant patients with hypertension in Ethiopia. It is clear and concise.

Keywords are appropriate

Figure 1.  Can add an arrow on the figure pointing to the hyperechoic mass in the center which is the concealed rupture placenta.

Figure 2 is labeled and clearly shows the placenta and clot from subacute rupture.

Both cases described a pregnant patient with HTN/preeclampsia requiring emergent intervention for the ruptured placenta. This is an important diagnosis to be aware of and recognize as abnormal on POCUS by emergency medicine physicians.

The long discussion paragraph should be broken up into separate paragraphs to improve readability. The content is great with logical flow. It describes the typical symptoms of abdominal pain and vaginal bleeding seen with PA, thus lack of other symptoms leads to the “concealed PA” diagnosis.

-A few sentences seem repetitive with the Figures/background.

-Consider adding what other risk factors can contribute to placental abruption besides hypertension (e.g. trauma such as motor vehicle accident, fall, cocaine use, etc.)

The images in Figure 1 &2 are clear and have labels that identify the pertinent structures.

References are updated and appropriate.

Author Response

We appreciate the reviewer's comments and provided replies below.

General: This paper is important because it describes the utility of POCUS in diagnosing concealed placental abruption, which can be a deadly and dangerous complication of pregnancy. This diagnosis is emergent and requires c-section in patients with pre-eclampsia and high blood pressure. The authors present two cases with clear image examples of concealed PA so that physicians can practice recognizing this pathology and in what types of patient presentation cases.

Title is appropriate and clear

Abstract: States the background and main findings of two patient cases of concealed placental abruption using POCUS in pregnant patients with hypertension in Ethiopia. It is clear and concise.

Keywords are appropriate

Reply: thanks for these comments.

Figure 1.  Can add an arrow on the figure pointing to the hyperechoic mass in the center which is the concealed rupture placenta.

Reply: thanks, added with reference in caption.

Figure 2 is labeled and clearly shows the placenta and clot from subacute rupture.

Both cases described a pregnant patient with HTN/preeclampsia requiring emergent intervention for the ruptured placenta. This is an important diagnosis to be aware of and recognize as abnormal on POCUS by emergency medicine physicians.

Reply: thanks for these comments.

The long discussion paragraph should be broken up into separate paragraphs to improve readability. The content is great with logical flow. It describes the typical symptoms of abdominal pain and vaginal bleeding seen with PA, thus lack of other symptoms leads to the “concealed PA” diagnosis.

-A few sentences seem repetitive with the Figures/background.

Reply: thanks for these comments. We agree with this observation. However, editorial indications are strictly recommending to avoid separate paragraphs. Therefore, we couldn't consider to provide a different format. We removed lines 94-95 to reduce repetitions.

-Consider adding what other risk factors can contribute to placental abruption besides hypertension (e.g. trauma such as motor vehicle accident, fall, cocaine use, etc.)

Reply: thanks. we added reference to this information in line 92

The images in Figure 1 &2 are clear and have labels that identify the pertinent structures.

References are updated and appropriate.

Reply: thanks for these comments.

Reviewer 2 Report

Comments and Suggestions for Authors

This case report explores the diagnosis and management of concealed placental abruption (PA) complicated by hypertensive disorders of pregnancy (HDP). The article demonstrates that point-of-care ultrasound (POC-US) holds significant value in clinical decision-making. The case images are clear, with comparisons between ultrasound findings and physical evidence, providing certain clinical relevance. I have the following questions for the authors to address:

1. While ultrasound is valuable for diagnosing PA, it also places certain demands on the operator, requiring experienced and technically proficient personnel. Were the operators in this study specifically trained? The technical background of the operators should be clarified in the article.

2. For cases where the placenta is located on the posterior uterine wall, ultrasound examination for PA can still pose certain challenges. Additionally, as the fetus grows, it may obscure the posterior placental view. The authors should address the limitations of ultrasound in such scenarios in the article to assist clinicians in selecting appropriate supplementary diagnostic methods.

Author Response

Thanks for the insightful comments, please find replies below.

This case report explores the diagnosis and management of concealed placental abruption (PA) complicated by hypertensive disorders of pregnancy (HDP). The article demonstrates that point-of-care ultrasound (POC-US) holds significant value in clinical decision-making. The case images are clear, with comparisons between ultrasound findings and physical evidence, providing certain clinical relevance. I have the following questions for the authors to address:

1. While ultrasound is valuable for diagnosing PA, it also places certain demands on the operator, requiring experienced and technically proficient personnel. Were the operators in this study specifically trained? The technical background of the operators should be clarified in the article.

Reply: thanks for the comment. in lines 116-119 we added:" In both cases, the US examination was performed by Integrated Emergency Surgical Officers, that are non-medical provider trained according to a specific National program that ensures the competence in obstetric POC-US"

2. For cases where the placenta is located on the posterior uterine wall, ultrasound examination for PA can still pose certain challenges. Additionally, as the fetus grows, it may obscure the posterior placental view. The authors should address the limitations of ultrasound in such scenarios in the article to assist clinicians in selecting appropriate supplementary diagnostic methods.

Reply: thanks. we added limitations in lines 130-132 "Nonetheless, the technical limitations of POC-US must be recognized: it remains highly operator-dependent and carries a risk of false-negative results, particularly in cases of posterior placentation where fetal shadowing may obscure the retroplacental interface."