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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: 1. Line 109-110: The authors mentioned exclusion criteria -- As this is a study about the reliability, I don't see why the authors had to exclude these women. If the study is a part of other studies that require these exclusion criteria, the authors should clarify.

2. Line 118: "(operator 1 and 2, operator 1 and 3, and operator 2 and 3)" gives meaning of each participant receive U/S from 3 sonographers, the authors might consider change to "(operator 1 and 2, operator 1 and 3, 'or' operator 2 and 3)."

3. The authors might consider mention about probe pressure during the measurement.

4. The authors might consider clarify more about the position of the U/S probe for the "cervix-placenta view"

5. Table 2 - misspelling "Wight circumference"

6. The method section mentioned Bland-Altman plots; however, I could not find the plot in the result section. The authors might rephrase the method section to make it align.

Reviewer #2: Thank you for asking me to review the manuscript entitled “Assessing the Reliability of Abdominal Adiposity Measurements by Transabdominal Ultrasound in First Trimester Pregnancies with Sonographers of Varying Experience Levels.”

Abstract: The abstract is well written

Introduction: Well written, however, I wonder why the authors refer to the in-text citation before citing examples (ref 1-2), (ref 3), and (ref 4-6). It is already known that the references are captured in the brackets, so there is no need to add ref to it!

Materials and Methods:

This was well written, however, what advised the choice of statistical analysis used by the authors? Was there a test for normality on the data before deciding which statistical analysis to use?

Did the authors run a positive and negative predictive values test for the study to determine the reliability of Ultrasound in adiposity biometry?

Results:

The result presentation is not very clear!

It started with Table 2? The information in Table 1 can be captured as figures and table 1 should tell us about the demographic characteristics of the study population.

What advised the selection of only 90 participants?

The tables are not self-explanatory, the lines within the tables should be removed!

Discussion:

This is well presented, however, the authors in making reference to intext citations mention both the initial and surnames of the authors like “NJ Kennedy et al. and Nassr AA et al. Which I think is incorrect, it should either be Kennedy et al., or Nassr et al.,.

The discussion is somewhat narrow or shallow, can authors expand on the discussion please?

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. pruksanusak,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

One reviewer has recommended rejecting your manuscript due to methodological concerns and questions regarding the generalizability of your findings to clinical practice, while another has advised major revision. In this context, you are encouraged to address these concerns thoroughly before your manuscript can proceed to the next stage of evaluation.

==============================

Please submit your revised manuscript by Jun 21 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Athanasios G. Pantelis

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

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3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #3: (No Response)

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

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Reviewer #3: I have 2 main concern: why did you select the first trimester? was it based on previous reports? we know that the fat deposits increase through second and third trimester, and these are the periods where pregnant women develop the actual insulin resistance. The second concern is the age. If you included younger women at 20th for example, this can remove the age factor of fat deposition. Also I wonder why did you select different levels of trainees to do the abdominal scan. As a first report in the country, you should put a solid background for future researches by conducting your study with expert hands. Also why did you excluded hypertensive women, hypertension alone has no impact on fat deposition unless itis related to obesity or diabetes

Reviewer #4: Gestational diabetes mellitus is a significant problem, and one of its risk factors is central obesity. A common tool for assessing body composition (BMI) does not capture central obesity, and thus is an imprecise indicator of the risk of GDM. In this study, the authors use ultrasound to measure central obesity in pregnant Asian people. Their aim in this study is to quantify the extent to which a clinician’s level of experience affects the reliability of ultrasonic measurements of body fat taken in three different areas where fat is deposited in the trunk. The results indicate that the ultrasonic measurements of body fat correlate well with hip-to-waist ratio, hip circumference, and waist circumference. Moreover the degree of intra- and inter-clinician variability in taking these measurements is quite minimal.

The paper is clearly written. The authors clearly and convincingly describe the shortcomings of BMI as a diagnostic tool, and present a convincing case in favor of new techniques to measure fat deposition in the trunk and thus more readily identify women at risk of GDM. The statistical methods appear sound, and the methods are clear. Table 1 is especially strong, as it shows exactly what differentiates the measurements taken at the different abdominal sites. In Tables 3 and 4 it is tricky to discern the most important comparisons the authors wish to draw our attention to. I wonder if every pairwise comparison needs to be presented. A summary could serve well, alternatively, the data in Tables 3 and 4 could perhaps be offered as supplemental materials.

I have one primary concern, which is that the findings of the manuscript on inter-practitioner variability don’t clearly stand on their own. That is, the results described in this manuscript on inter-sonographer variability would be a crucial component of a larger study establishing the validity, relevance, or predictive value of the method itself. Such a methods paper might look at whether or not abdominal ultrasound compared favorably to other methods of measuring body composition such as body densitometry, CT, or MRI. Or, as seems to be the case here (based on my reading of an earlier response to reviewers), such a methods paper might look at the predictive value of ultrasound in assessing the risk of gestational diabetes. But these findings on measurement variability alone are presently separated from a context in which they would become compelling, and reach a wider audience.

Reviewer #5: Summary

This study is significant and has relevance in maintaining the health of both the mother and fetus. The aim and objective of the study were achieved through the different methods, results and the discussion. The study targeted the right subjects and the tools were non-invasive which made the methods more attractive. And elicited low or no discomfort to the pregnant women during their applications.

Abstract

Can the reason why these tools were considered be incorporated in the abstract?

Yes, it is to measure the abdominal adiposity in pregnancy. But why? Line 28…. Let the correlation between the measurement of the abdominal adiposity and gestational diabetes mellitus be incorporated.

Introduction

Line 66…. Gave the reasons why this study was conducted, however, I believe this tool would be used in conjunction with other known methods in determining/diagnosing gestational diabetes mellitus.

Materials and Methods

Line 119 – 122…. What informed you of these 3 locations for the measurements?

Results

Line 153 – 155…. The probability that the procedure and results would be affected by experience of the operators was expected to be high as rightly indicated in this study. However, line 158, interestedly showed that VFT was not affected by experience.

Discussion

Line 181… this sentence should be reworded. ‘For Thai population, one study found similar results to ours with high intraobserver reliability (ICC 0.96)’ …. It could have be written as ‘our result was similar to a previous study which had a high intraobserver reliability’ (ICC 0.96). My understanding is that you compare new study with previous studies.

Figures and Tables: They were simple, self-explanatory, easy to the eye and well labelled.

Reviewer #6: 83- difference ---- it should be different

90-- research and contribute to the development of more effective GDM screening strategies---you are writing in introduction theseu/s technique for screeing of GDM --but already simple and reliable methods are there and only OBESITY is not the risk factor for GDM

118---------operators are not equally distributed as far as experence is concerned

121----- the cervix-placenta view need some explanaition how it measures and detect VF

190---------again your focus on prediction of GDM but can you explain that when other simple methods are availble then with this technique and it is obviuos experenced operator has more relable result so why the article only check the reliabilty of operators

then authour did not mention that how much it has predictive value in screening GDM as your introduction is emaphasiszing on it

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Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes:  professor farzana rizwan arain

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Attachments

Attachment

Submitted filename: Review_OBSTETRICS ARTICLE.pdf

Assessing the Reliability of Abdominal Adiposity Measurements by Transabdominal Ultrasound in First Trimester Pregnancies with Sonographers of Varying Experience Levels

PONE-D-24-49281R2

Dear Dr. Pruksanusak,

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

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Kind regards,

Athanasios G. Pantelis

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Dr. Pruksanusak and colleagues,

Thank you for your detailed responses to the reviewers’ comments and for submitting the revised version of your manuscript titled: “Assessing the reliability of abdominal adiposity measurements by transabdominal ultrasound in first trimester pregnancies with sonographers of varying experience levels” (PONE-D-24-49281R2).

I appreciate the effort you put into addressing the reviewers’ concerns. Your clarifications and the added content significantly enhance the manuscript’s clarity and value, particularly in reinforcing its methodological contribution to the field.

I would like to offer my sincere apologies for the prolonged editing time and thank you for your patience throughout the process.

Before proceeding to final acceptance, I kindly ask that you make a few minor language corrections to address small typographical and grammatical issues noted in the current version (e.g., “aimsT” in the Abstract, redundant phrasing in the Introduction, missing punctuation in the Discussion).

Once these final edits are incorporated, your manuscript will be ready for publication.