const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3 x 7.5
pres.author = "MD Medicine CME";
pres.title = "Pathological Disorders in Pregnancy: Liver, Thyroid & Heart";

// ─── Color palette ──────────────────────────────────────────────
const DEEP_NAVY = "0D2137";      // dominant background
const MIDNIGHT = "112244";       // secondary dark
const TEAL = "1A7F8E";           // accent headers
const TEAL_LIGHT = "22A8B8";     // sub-accents
const GOLD = "E8B84B";           // highlights / icons
const CREAM = "F4F0E8";          // body text
const WHITE = "FFFFFF";
const LIGHT_GRAY = "D8E3EC";
const SECTION_LIVER = "1A4D3A";  // dark green for liver slides
const SECTION_THYROID = "2C2A6E";// dark indigo for thyroid
const SECTION_HEART = "5A1A1A";  // dark crimson for heart

// ─── Helper: add slide background rect ──────────────────────────
function bg(slide, color) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color } });
}

// ─── Helper: top accent bar ─────────────────────────────────────
function topBar(slide, color) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.12, fill: { color } });
}

// ─── Helper: bottom accent bar ──────────────────────────────────
function bottomBar(slide, color) {
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}

// ─── Helper: section header bar (left strip) ────────────────────
function leftStrip(slide, color) {
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}

// ─── Helper: title text on dark slides ──────────────────────────
function addTitle(slide, text, y = 0.28, color = GOLD) {
  slide.addText(text, {
    x: 0.4, y, w: 12.5, h: 0.65,
    fontSize: 30, bold: true, color,
    fontFace: "Calibri Light",
    margin: 0,
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}

// ─── Helper: subtitle line ──────────────────────────────────────
function addSubtitle(slide, text, y = 0.92, color = TEAL_LIGHT) {
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    fontSize: 14, bold: false, color,
    fontFace: "Calibri",
    margin: 0,
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}

// ─── Helper: horizontal divider ─────────────────────────────────
function divider(slide, y = 1.22, color = TEAL) {
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}

// ─── Helper: bullet list body text ──────────────────────────────
function addBullets(slide, items, x = 0.5, y = 1.4, w = 12.2, fontSize = 13.5, color = CREAM) {
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    fontFace: "Calibri",
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}

// ─── Helper: two-column layout ──────────────────────────────────
function addTwoCols(slide, leftItems, rightItems, y = 1.4, fontSize = 13) {
  const mkArr = (items) => items.map((item, i) => {
    const isHeader = item.startsWith("##");
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        bullet: isHeader ? false : { indent: isSub ? 25 : 8 },
        bold: isHeader,
        color: isHeader ? GOLD : (isSub ? LIGHT_GRAY : CREAM),
        fontSize: isHeader ? fontSize + 1 : (isSub ? fontSize - 1 : fontSize),
        breakLine: i < items.length - 1,
        paraSpaceBefore: isHeader ? 5 : 0,
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    x: 0.4, y, w: 6.15, h: 7.5 - y - 0.15,
    fontFace: "Calibri", valign: "top",
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  // divider
  slide.addShape(pres.ShapeType.rect, { x: 6.7, y, w: 0.03, h: 7.5 - y - 0.15, fill: { color: TEAL } });
  slide.addText(mkArr(rightItems), {
    x: 6.85, y, w: 6.05, h: 7.5 - y - 0.15,
    fontFace: "Calibri", valign: "top",
  });
}

// ─── Helper: source footer ──────────────────────────────────────
function addSource(slide, text) {
  slide.addText(text, {
    x: 0.4, y: 7.2, w: 12.5, h: 0.22,
    fontSize: 9.5, color: "7A99BB", italic: true, fontFace: "Calibri",
    margin: 0,
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  topBar(s, GOLD);
  bottomBar(s, TEAL);

  // large dark shape left panel
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.6, h: "100%", fill: { color: TEAL } });

  // rotated vertical text on left strip
  s.addText("PATHOLOGICAL DISORDERS IN PREGNANCY", {
    x: -2.8, y: 3.4, w: 7.0, h: 0.5,
    fontSize: 10, color: WHITE, bold: true, rotate: 270,
    fontFace: "Calibri", charSpacing: 3, margin: 0,
  });

  s.addText("Pathological Disorders in Pregnancy", {
    x: 1.0, y: 1.2, w: 11.0, h: 1.1,
    fontSize: 42, bold: true, color: GOLD,
    fontFace: "Calibri Light", align: "left",
  });

  s.addText("Liver  •  Thyroid  •  Heart", {
    x: 1.0, y: 2.35, w: 11.0, h: 0.65,
    fontSize: 28, bold: false, color: TEAL_LIGHT,
    fontFace: "Calibri Light", align: "left",
  });

  s.addShape(pres.ShapeType.rect, { x: 1.0, y: 3.1, w: 8.0, h: 0.05, fill: { color: TEAL } });

  s.addText("For MD Medicine & Postgraduate Examination Preparation", {
    x: 1.0, y: 3.25, w: 11.0, h: 0.45,
    fontSize: 16, color: LIGHT_GRAY, fontFace: "Calibri",
  });

  s.addText([
    { text: "Sources: ", options: { bold: true, color: GOLD } },
    { text: "Sleisenger & Fordtran's GI & Liver Disease  •  Braunwald's Heart Disease  •  Creasy & Resnik's Maternal-Fetal Medicine  •  Berek & Novak's Gynecology  •  Harrison's Principles of Internal Medicine 22e  •  Yamada's Gastroenterology", options: { color: LIGHT_GRAY } },
  ], {
    x: 1.0, y: 3.85, w: 11.5, h: 0.9,
    fontSize: 11, fontFace: "Calibri",
  });

  // three colored circles for sections
  const circles = [
    { x: 1.2, color: "1A4D3A", label: "LIVER" },
    { x: 4.2, color: "2C2A6E", label: "THYROID" },
    { x: 7.2, color: "5A1A1A", label: "HEART" },
  ];
  circles.forEach(c => {
    s.addShape(pres.ShapeType.ellipse, { x: c.x, y: 5.1, w: 2.0, h: 2.0, fill: { color: c.color }, line: { color: GOLD, width: 2 } });
    s.addText(c.label, {
      x: c.x, y: 5.1, w: 2.0, h: 2.0,
      fontSize: 18, bold: true, color: WHITE, align: "center", valign: "middle",
      fontFace: "Calibri Light", margin: 0,
    });
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 2 — TABLE OF CONTENTS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  topBar(s, GOLD);
  bottomBar(s, TEAL);

  addTitle(s, "Table of Contents", 0.25);
  divider(s, 0.92);

  const sections = [
    { num: "SECTION 1", title: "Normal Physiological Changes in Pregnancy", color: TEAL_LIGHT },
    { num: "SECTION 2", title: "Liver Disorders Unique to Pregnancy", color: "4CAF82" },
    { num: "SECTION 3", title: "Hyperemesis Gravidarum & Viral Hepatitis", color: "4CAF82" },
    { num: "SECTION 4", title: "Thyroid Physiology & Hypothyroidism in Pregnancy", color: "7B7FD4" },
    { num: "SECTION 5", title: "Hyperthyroidism, Graves Disease & Postpartum Thyroiditis", color: "7B7FD4" },
    { num: "SECTION 6", title: "Cardiovascular Changes & Risk Stratification", color: "E07070" },
    { num: "SECTION 7", title: "Cardiomyopathies & Peripartum Cardiomyopathy", color: "E07070" },
    { num: "SECTION 8", title: "Valvular Heart Disease, Arrhythmias & CHD in Pregnancy", color: "E07070" },
    { num: "SECTION 9", title: "Drug Safety & Multidisciplinary Management", color: GOLD },
  ];

  sections.forEach((sec, i) => {
    const y = 1.1 + i * 0.65;
    s.addShape(pres.ShapeType.rect, { x: 0.5, y, w: 1.5, h: 0.5, fill: { color: sec.color } });
    s.addText(sec.num, {
      x: 0.5, y, w: 1.5, h: 0.5,
      fontSize: 9, bold: true, color: DEEP_NAVY, align: "center", valign: "middle",
      fontFace: "Calibri", margin: 0,
    });
    s.addText(sec.title, {
      x: 2.2, y: y + 0.08, w: 10.5, h: 0.36,
      fontSize: 14.5, color: CREAM, fontFace: "Calibri",
      margin: 0,
    });
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 3 — PHYSIOLOGICAL CHANGES IN PREGNANCY
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  topBar(s, TEAL);
  bottomBar(s, GOLD);
  addTitle(s, "Normal Physiological Changes in Pregnancy", 0.2, TEAL_LIGHT);
  divider(s, 0.85, GOLD);

  const left = [
    "## Hemodynamic Changes",
    "Plasma volume ↑ 40–50% (greatest by 32 wks)",
    "Cardiac output ↑ 30–50% (↑HR + ↑SV)",
    "SVR ↓ → systolic BP slightly ↓",
    "Blood pressure nadir at ~20 weeks, rises near term",
    "## Hepatic Changes",
    "Serum albumin ↓ (dilutional); ALP ↑ 2–4×",
    "ALT, AST, GGT, bilirubin remain normal",
    "Clotting factors (I, VII, VIII, X) ↑ — hypercoagulable state",
    "Protein C/S ↓; fibrinolysis ↓",
    "Mild spider angiomas & palmar erythema — estrogen effect",
  ];

  const right = [
    "## Thyroid Changes",
    "hCG weakly stimulates TSH receptor → FT4 ↑, TSH ↓ in T1",
    "TBG ↑ (estrogen) → total T4/T3 ↑",
    "Free T4 (FT4) normal to slightly ↓ in T2/T3",
    "Thyroid volume ↑ 10–15%; iodine requirement ↑",
    "## Renal & Metabolic",
    "GFR ↑ 50%; creatinine & urea ↓",
    "Glucosuria possible even with normal glucose",
    "Prolactin levels rise progressively",
    "## Coagulation Summary",
    "Prothrombotic state; D-dimer ↑ (normal ranges differ in pregnancy)",
  ];

  addTwoCols(s, left, right, 1.0, 13);
  addSource(s, "Harrison's Principles of Internal Medicine 22e; Creasy & Resnik's Maternal-Fetal Medicine");
}


// ════════════════════════════════════════════════════════════════
// SECTION DIVIDER — LIVER
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, SECTION_LIVER);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: "0A3027", transparency: 0 } });

  s.addShape(pres.ShapeType.ellipse, { x: 4.15, y: 1.5, w: 5.0, h: 5.0, fill: { color: "1F7A55", transparency: 30 }, line: { color: "4CAF82", width: 2 } });

  s.addText("SECTION 1", {
    x: 0, y: 1.9, w: "100%", h: 0.5,
    fontSize: 16, color: "4CAF82", bold: true, align: "center", charSpacing: 8,
    fontFace: "Calibri",
  });
  s.addText("LIVER DISORDERS", {
    x: 0, y: 2.5, w: "100%", h: 1.0,
    fontSize: 52, color: WHITE, bold: true, align: "center",
    fontFace: "Calibri Light",
  });
  s.addText("IN PREGNANCY", {
    x: 0, y: 3.55, w: "100%", h: 0.6,
    fontSize: 32, color: "4CAF82", bold: false, align: "center",
    fontFace: "Calibri Light",
  });
  s.addText("Unique liver diseases  •  HELLP  •  ICP  •  AFLP  •  Pre-existing liver disease", {
    x: 0, y: 4.5, w: "100%", h: 0.4,
    fontSize: 14, color: LIGHT_GRAY, align: "center", fontFace: "Calibri",
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 4 — LIVER DISEASES UNIQUE TO PREGNANCY (OVERVIEW)
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  leftStrip(s, SECTION_LIVER);
  topBar(s, "4CAF82");

  addTitle(s, "Liver Diseases Unique to Pregnancy — Classification", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  // table-style layout
  const rows = [
    ["Trimester", "Disorder", "Key Feature"],
    ["T1", "Hyperemesis Gravidarum", "Nausea/vomiting → mild AST/ALT ↑ (up to 200 U/L)"],
    ["T1–T3", "Intrahepatic Cholestasis of Pregnancy (ICP)", "Pruritus; bile acids ↑; fetal risk of stillbirth"],
    ["T2–T3", "Pre-eclampsia / Eclampsia (Liver)", "RUQ pain, HTN, proteinuria; periportal necrosis"],
    ["T2–T3", "HELLP Syndrome", "Hemolysis + ↑LFTs + Thrombocytopenia; risk of hepatic rupture"],
    ["T3 / Postpartum", "Acute Fatty Liver of Pregnancy (AFLP)", "Microvesicular steatosis; liver failure; DIC; LCHAD mutation"],
    ["Any", "Viral Hepatitis (HAV, HBV, HCV, HEV)", "HEV most severe in pregnancy (20–30% mortality)"],
    ["Any", "Pre-existing disease (PBC, AIH, Wilson's)", "Exacerbation/improvement based on immune modulation"],
  ];

  const colW = [1.8, 3.8, 7.0];
  const colX = [0.4, 2.3, 6.2];
  const colors = ["2B5C40", "243D5C"]; // alternating row colors

  rows.forEach((row, i) => {
    const y = 0.97 + i * 0.73;
    const isHeader = i === 0;
    row.forEach((cell, j) => {
      s.addShape(pres.ShapeType.rect, {
        x: colX[j], y,
        w: colW[j] - 0.05, h: 0.68,
        fill: { color: isHeader ? TEAL : (i % 2 === 0 ? colors[0] : colors[1]) },
        line: { color: TEAL, width: 0.5 },
      });
      s.addText(cell, {
        x: colX[j] + 0.06, y: y + 0.04,
        w: colW[j] - 0.15, h: 0.6,
        fontSize: isHeader ? 12 : 11.5,
        bold: isHeader,
        color: isHeader ? WHITE : CREAM,
        fontFace: "Calibri",
        valign: "middle",
        margin: 0,
      });
    });
  });

  addSource(s, "Sleisenger & Fordtran's GI & Liver Disease; Goldman-Cecil Medicine; Harrison's 22e");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 5 — INTRAHEPATIC CHOLESTASIS OF PREGNANCY (ICP)
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  leftStrip(s, SECTION_LIVER);
  topBar(s, "4CAF82");

  addTitle(s, "Intrahepatic Cholestasis of Pregnancy (ICP)", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  const left = [
    "## Definition & Epidemiology",
    "Reversible, hormone-sensitive cholestasis of T2–T3",
    "Incidence 0.1–1.5% (higher in South America, Scandinavia)",
    "Genetic: ABCB11 (BSEP), ABCB4, ATP8B1 mutations",
    "## Pathophysiology",
    "Estrogen/progesterone impair bile canalicular transport (BSEP)",
    "Serum bile acids accumulate → pruritus & fetal toxicity",
    "## Clinical Features",
    "Intense pruritus — palms & soles, worse at night",
    "No primary skin lesions; excoriations only",
    "Jaundice in 10–25% (serum bilirubin ↑)",
    "Steatorrhea if severe cholestasis → Vit K deficiency",
  ];

  const right = [
    "## Investigations",
    "Serum bile acids >10 μmol/L (hallmark); >40 μmol/L = severe",
    "ALT/AST mildly-moderately ↑; ALP ↑ (placental)",
    "GGT usually normal (unlike drug cholestasis)",
    "PT: check if jaundiced (Vit K deficiency risk)",
    "## Fetal Risks",
    "Preterm birth (spontaneous), stillbirth, meconium passage",
    "Fetal arrhythmia (bile acids toxic to myocardium)",
    "Risk of stillbirth ↑ with bile acids >40 μmol/L",
    "## Treatment",
    "Ursodeoxycholic acid (UDCA) 10–15 mg/kg/day — 1st line",
    "Vitamin K supplementation if jaundiced",
    "Delivery at 36–37 weeks (or earlier if severe)",
    "Prognosis: resolves within days of delivery",
  ];

  addTwoCols(s, left, right, 1.0, 12.5);
  addSource(s, "Sleisenger & Fordtran's (block8); Yamada's Gastroenterology 7e; Dermatology 5e");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 6 — HELLP SYNDROME
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  leftStrip(s, SECTION_LIVER);
  topBar(s, "4CAF82");

  addTitle(s, "HELLP Syndrome", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  const left = [
    "## Definition (Weinstein, 1982)",
    "Hemolysis + Elevated Liver enzymes + Low Platelets",
    "Complicates 0.2–0.8% all pregnancies",
    "Up to 12% of severe pre-eclampsia cases",
    "## Tennessee Classification",
    "Microangiopathic hemolysis (schistocytes on smear)",
    "LDH >600 IU/L OR AST >70 IU/L OR bilirubin >1.2 mg/dL",
    "Platelets <100,000/μL",
    "## Mississippi Triple Class",
    "Class 1: platelets ≤50,000/μL",
    "Class 2: 50,000–100,000/μL",
    "Class 3: 100,000–150,000/μL",
    "## Symptoms",
    "RUQ / epigastric pain (most common)",
    "Nausea, vomiting, headache, blurred vision",
    "Malaise — may mimic viral syndrome",
    "30% present AFTER delivery despite no preeclampsia at delivery",
  ];

  const right = [
    "## Complications",
    "Subcapsular hematoma → hepatic rupture (life-threatening)",
    "Acute kidney injury; DIC; pulmonary edema",
    "Placental abruption; retinal detachment",
    "## Investigations",
    "Blood smear: schistocytes, burr cells",
    "↑ LDH, ↑ AST/ALT, ↑ bilirubin, ↓ haptoglobin",
    "↓ Platelets; ↑ PT/APTT (if DIC)",
    "Uric acid ↑; creatinine ↑ if AKI",
    "## Management",
    "Immediate hospitalization; fetal monitoring",
    "Corticosteroids (betamethasone for fetal lung maturity <34 wks)",
    "Antihypertensives: labetalol, hydralazine, nifedipine",
    "Magnesium sulfate — seizure prophylaxis",
    "Definitive: DELIVERY (CS preferred ≥34 wks or unstable)",
    "Platelet transfusion if <20,000/μL or active bleeding",
  ];

  addTwoCols(s, left, right, 0.98, 12);
  addSource(s, "Sleisenger & Fordtran's GI & Liver Disease (block 8, p. 4051–4064); Creasy & Resnik's MFM (block 11)");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 7 — ACUTE FATTY LIVER OF PREGNANCY (AFLP)
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  leftStrip(s, SECTION_LIVER);
  topBar(s, "4CAF82");

  addTitle(s, "Acute Fatty Liver of Pregnancy (AFLP)", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  const left = [
    "## Epidemiology",
    "Incidence: 1 in 7,000–20,000 deliveries",
    "Most common: T3 (after 30 wks), primiparity, twins, male fetus",
    "## Pathophysiology",
    "LCHAD (long-chain 3-hydroxyacyl CoA dehydrogenase) deficiency",
    "  - Fetal LCHAD mutation → toxic metabolites to mother",
    "  - G1528C mutation on α-subunit of trifunctional protein",
    "Microvesicular fat infiltrates hepatocytes (perivenular)",
    "  - Distinct from macrovesicular steatosis",
    "Leads to hepatic failure, DIC, encephalopathy",
    "## Swansea Criteria (diagnosis — 6 of 14 features required)",
    "Vomiting, abdominal pain, polydipsia/polyuria",
    "↑ Bilirubin, ↑ creatinine (>150 μmol/L), ↑ uric acid",
    "Hypoglycemia, coagulopathy (PT >14s), WBC >11×10⁹/L",
    "AST/ALT ↑, ammonia ↑, encephalopathy",
    "Microvesicular steatosis on biopsy / imaging",
  ];

  const right = [
    "## Clinical Features",
    "Prodrome: nausea, vomiting, abdominal pain, fatigue",
    "Jaundice (moderate to deep)",
    "Acute liver failure: encephalopathy, coagulopathy",
    "DIC: bleeding from IV sites, hematuria",
    "Hypoglycemia (impaired gluconeogenesis)",
    "Acute kidney injury common",
    "## Histopathology (gold standard)",
    "Microvesicular fat in centrilobular hepatocytes",
    "Pleomorphic vacuolated hepatocytes, lobular disarray",
    "No significant necrosis (contrast with HELLP)",
    "## Management",
    "ICU admission; multidisciplinary team",
    "Correct hypoglycemia: 10% dextrose infusion",
    "FFP, cryoprecipitate, platelets for coagulopathy",
    "URGENT DELIVERY — definitive treatment",
    "Neonates: screen for LCHAD deficiency",
    "Prognosis: with early delivery, maternal mortality <2%",
    "Recurrence risk in subsequent pregnancies: ~20%",
  ];

  addTwoCols(s, left, right, 0.98, 12);
  addSource(s, "Sleisenger & Fordtran's (block 8, p. 4201+); Yamada's Gastroenterology 7e; Comprehensive Clinical Nephrology 7e");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 8 — HYPEREMESIS GRAVIDARUM + HEPATITIS IN PREGNANCY
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s, DEEP_NAVY);
  leftStrip(s, SECTION_LIVER);
  topBar(s, "4CAF82");

  addTitle(s, "Hyperemesis Gravidarum & Viral Hepatitis in Pregnancy", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  const left = [
    "## Hyperemesis Gravidarum (HG)",
    "Severe nausea/vomiting; dehydration; weight loss >5%",
    "T1 onset (4–8 wks); peaks ~10–12 wks",
    "Liver: ALT/AST ↑ up to 200 U/L (mild, self-limiting)",
    "  - Elevation correlates with degree of dehydration",
    "Bilirubin mildly ↑; no frank liver failure",
    "Treat: IV fluids, thiamine (prevent Wernicke's)",
    "  - Antiemetics: ondansetron, metoclopramide",
    "  - Methylprednisolone for refractory HG",
    "## Pre-existing Liver Disease in Pregnancy",
    "PBC: ursodeoxycholic acid safe; pruritus worsens",
    "Autoimmune hepatitis: improve in pregnancy (immune tolerance)",
    "  - Flare common postpartum",
    "  - Continue azathioprine (do NOT stop — risk > benefit)",
    "Wilson's disease: continue penicillamine (low dose) or trientine",
    "Portal hypertension: ↑ variceal bleed risk (↑ portal flow)",
  ];

  const right = [
    "## Viral Hepatitis A (HAV)",
    "Usually self-limiting; no vertical transmission",
    "Risk of preterm birth if severe",
    "## Viral Hepatitis B (HBV)",
    "Vertical transmission risk 70–90% (if HBeAg+ mother)",
    "All infants: HBV vaccine + HBIG within 12 hours of birth",
    "TDF (tenofovir) safe in T3 if HBV DNA >200,000 IU/mL",
    "## Viral Hepatitis C (HCV)",
    "Vertical transmission 5–6% (↑ if HIV co-infection)",
    "DAAs (direct acting antivirals) contraindicated in pregnancy",
    "## Hepatitis E (HEV) — most dangerous",
    "Genotype 1/2 endemic in South Asia, Africa",
    "Maternal mortality 20–30% in T3 (immune dysregulation)",
    "Fulminant hepatic failure, DIC",
    "No approved antiviral; ribavirin contraindicated",
    "Supportive care; early delivery if viable",
    "## HSV Hepatitis (rare, severe)",
    "Presents with fulminant liver failure",
    "IV acyclovir is life-saving; high maternal mortality if untreated",
  ];

  addTwoCols(s, left, right, 1.0, 12);
  addSource(s, "Sleisenger & Fordtran's GI & Liver Disease; Yamada's Gastroenterology 7e; Creasy & Resnik's MFM");
}


// ════════════════════════════════════════════════════════════════
// SECTION DIVIDER — THYROID
// ════════════════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.ellipse, { x: 4.15, y: 1.5, w: 5.0, h: 5.0, fill: { color: "3D3A9E", transparency: 30 }, line: { color: "7B7FD4", width: 2 } });

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    x: 0, y: 2.5, w: "100%", h: 1.0,
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    x: 0, y: 3.55, w: "100%", h: 0.6,
    fontSize: 32, color: "7B7FD4", bold: false, align: "center", fontFace: "Calibri Light",
  });
  s.addText("Physiology  •  Hypothyroidism  •  Hyperthyroidism  •  Graves  •  Postpartum Thyroiditis", {
    x: 0, y: 4.5, w: "100%", h: 0.4,
    fontSize: 14, color: LIGHT_GRAY, align: "center", fontFace: "Calibri",
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 9 — THYROID PHYSIOLOGY IN PREGNANCY
// ════════════════════════════════════════════════════════════════
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  leftStrip(s, SECTION_THYROID);
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  addTitle(s, "Thyroid Physiology in Pregnancy", 0.2, "7B7FD4");
  divider(s, 0.87, "7B7FD4");

  const left = [
    "## hCG–Thyroid Axis (T1)",
    "hCG peaks at 10–12 wks → acts on TSH receptor",
    "  - Causes mild FT4 ↑ and TSH ↓ (gestational transient thyrotoxicosis)",
    "Normal TSH range lower in T1 (0.1–2.5 mIU/L)",
    "TSH lower limit: 0.1 mIU/L T1 → 0.2 T2 → 0.3 T3",
    "## TBG Changes",
    "Estrogen ↑ TBG → total T4/T3 ↑ (not biologically active)",
    "Free T4 normal to slightly ↓ in T2 and T3",
    "Must use trimester-specific reference ranges",
    "## Iodine Requirement",
    "Pregnancy: iodine requirement ↑ (150 → 250 μg/day)",
    "Thyroid volume ↑ 10–15% (endemic areas more)",
    "Iodine deficiency → maternal/fetal hypothyroidism",
    "Iodine deficiency: leading preventable cause of intellectual disability",
  ];

  const right = [
    "## Placenta & Thyroid Hormones",
    "TRH crosses placenta; TSH does NOT",
    "T4 crosses placenta (limited, important early)",
    "TSHRAb (Graves) and antithyroid drugs cross placenta",
    "Fetal thyroid functional from 10–12 wks",
    "Fetal T4 depends on maternal iodine supply",
    "## Reference Ranges (Trimester-Specific)",
    "TSH: T1 0.1–2.5; T2 0.2–3.0; T3 0.3–3.0 mIU/L",
    "FT4: depends on assay and trimester",
    "## Screening Recommendations",
    "Universal screening controversial (ATA: screen high-risk)",
    "High-risk: history thyroid disease, DM1, goiter, TPO-Ab+",
    "Check TSH at first antenatal visit in high-risk",
    "TPO antibodies: predict postpartum thyroiditis",
  ];

  addTwoCols(s, left, right, 1.0, 12.5);
  addSource(s, "Berek & Novak's Gynecology (block 10, p.1993); Harrison's 22e; Creasy & Resnik's MFM (block 16)");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 10 — HYPOTHYROIDISM IN PREGNANCY
// ════════════════════════════════════════════════════════════════
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  addTitle(s, "Hypothyroidism in Pregnancy", 0.2, "7B7FD4");
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  const left = [
    "## Overt Hypothyroidism",
    "TSH >trimester upper limit + low FT4",
    "Prevalence: 0.3–0.5% in pregnancy",
    "Causes: Hashimoto's thyroiditis (commonest), post-ablation/surgery",
    "## Subclinical Hypothyroidism",
    "TSH elevated + NORMAL FT4",
    "Prevalence: 2–3% in pregnancy",
    "TPO antibody positive in many cases",
    "## Maternal Risks",
    "Miscarriage, placental abruption, preeclampsia",
    "Postpartum hemorrhage, anemia",
    "Preterm birth, low birth weight",
    "## Fetal/Neonatal Risks",
    "Intellectual disability (IQ points lost if untreated)",
    "Neonatal hypothyroidism (1 in 3500–4000 births)",
    "Impaired neuromotor development",
    "Congenital hypothyroidism → cretinism if severe",
  ];

  const right = [
    "## Treatment — Levothyroxine (LT4)",
    "Start or continue if TSH elevated with symptoms",
    "Overt: treat always; subclinical: treat if TPO-Ab+",
    "  - Or if TSH >10 mIU/L even if TPO-Ab negative",
    "Dose ↑ 25–50% as soon as pregnancy confirmed",
    "  - LT4 absorption changes with gestational age",
    "Target TSH: T1 <2.5; T2-T3 <3.0 mIU/L",
    "Monitor TSH every 4 weeks in T1, then every trimester",
    "Post-delivery: reduce to pre-pregnancy dose",
    "## Drug Interactions",
    "Calcium, iron, PPIs → take LT4 4 hrs before/after",
    "Prenatal vitamins often contain calcium/iron",
    "## Congenital Hypothyroidism Screening",
    "Neonatal TSH screen (heel prick, day 2–5)",
    "High TSH → confirm → start LT4 immediately",
    "Normal cognitive development if treated early",
  ];

  addTwoCols(s, left, right, 1.0, 12.5);
  addSource(s, "Berek & Novak's Gynecology; Creasy & Resnik's MFM; Tietz Textbook of Laboratory Medicine 7e; ATA 2017 Guidelines");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 11 — HYPERTHYROIDISM & GRAVES DISEASE IN PREGNANCY
// ════════════════════════════════════════════════════════════════
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  addTitle(s, "Hyperthyroidism & Graves Disease in Pregnancy", 0.2, "7B7FD4");
  divider(s, 0.87, "7B7FD4");

  const left = [
    "## Causes of Hyperthyroidism in Pregnancy",
    "Graves disease (most common — 85%)",
    "Gestational transient thyrotoxicosis (hCG-mediated)",
    "Toxic multinodular goiter / solitary toxic nodule",
    "Subacute/silent/postpartum thyroiditis",
    "Molar pregnancy / choriocarcinoma (hCG excess)",
    "## Graves Disease",
    "TSHRAb (stimulatory) activates TSH receptor",
    "Tends to IMPROVE in T2/T3 (immune tolerance)",
    "May WORSEN in T1 and postpartum",
    "TSHRAb crosses placenta → fetal/neonatal hyperthyroidism",
    "  - Occurs in 2–10% of pregnancies with Graves",
    "  - 16% neonatal mortality if untreated",
    "Maternal: spontaneous abortion, preterm, IUGR, stillbirth",
    "## Diagnosis",
    "Low/undetectable TSH + elevated FT4",
    "TSHRAb (TRAb) positive",
    "Radioiodine uptake scan CONTRAINDICATED in pregnancy",
  ];

  const right = [
    "## Antithyroid Drug Therapy",
    "PTU (propylthiouracil) preferred in T1",
    "  - Methimazole teratogenic in T1 (aplasia cutis, choanal atresia)",
    "  - Switch to methimazole in T2 (PTU hepatotoxicity risk)",
    "Target: maintain FT4 in upper-normal range",
    "  - Avoid hypothyroidism (blocks fetal thyroid)",
    "Monitor TRAb at 18–22 wks → predict neonatal disease",
    "## Fetal Monitoring",
    "Fetal USS: goiter, heart rate, bone maturation",
    "Fetal tachycardia >160 bpm → concern for hyperthyroidism",
    "Cordocentesis if clinical doubt and TRAb+ mother",
    "## Thyroid Storm (Thyrotoxic Crisis)",
    "Precipitated by surgery, infection, labor",
    "Fever, tachycardia, agitation, CHF, vomiting",
    "Burch-Wartofsky score >45 = storm likely",
    "Rx: PTU loading dose → KI (1 hr later) → β-blocker",
    "  - Hydrocortisone, cooling measures, ICU",
    "## Surgery",
    "Thyroidectomy: safest in T2 if drugs fail/toxic",
    "Radioiodine: ABSOLUTELY CONTRAINDICATED during pregnancy",
  ];

  addTwoCols(s, left, right, 1.0, 12);
  addSource(s, "Berek & Novak's Gynecology (block 10, p. 1988–1994); Creasy & Resnik's MFM (block 16)");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 12 — POSTPARTUM THYROID DYSFUNCTION
// ════════════════════════════════════════════════════════════════
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  const left = [
    "## Postpartum Thyroiditis (PPT)",
    "Incidence: 5–10% of women postpartum",
    "Autoimmune lymphocytic thyroiditis (rebound immune activation)",
    "Anti-TPO antibodies almost always positive",
    "## Criteria for Diagnosis",
    "(i) No prior thyroid disease during pregnancy",
    "(ii) Abnormal TSH within 1st year postpartum",
    "(iii) Negative TRAb (excludes Graves disease)",
    "## Classic Triphasic Pattern",
    "Phase 1 (1–3 months): Thyrotoxic phase (painless, transient)",
    "  - ↑ FT4, ↓ TSH; low radioiodine uptake",
    "  - Palpitations, anxiety, fatigue, weight loss",
    "Phase 2 (3–6 months): Hypothyroid phase",
    "  - ↑ TSH, ↓ FT4; fatigue, cold intolerance, depression",
    "  - Often confused with postpartum depression",
    "Phase 3 (6–12 months): Recovery/euthyroid phase",
    "20–40% permanent hypothyroidism at 5–7 years",
  ];

  const right = [
    "## Risk Factors",
    "Type 1 diabetes mellitus (25% risk)",
    "TPO-Ab+ in T1 of pregnancy",
    "Prior postpartum thyroiditis",
    "Family or personal history of autoimmune disease",
    "## Differentiation from Graves Disease",
    "Postpartum thyrotoxicosis: TRAb negative, uptake low",
    "Graves: TRAb positive, uptake elevated",
    "## Management",
    "Thyrotoxic phase: β-blockers if symptomatic; NO antithyroid drugs",
    "Hypothyroid phase: LT4 if symptomatic or planning next pregnancy",
    "Monitor TSH at 6 weeks, 3, 6, 12 months postpartum",
    "Discontinue LT4 after 6–12 months; re-check TSH",
    "## Counseling",
    "Recurrence in subsequent pregnancies (~70%)",
    "Annual TSH after resolution (permanent hypothyroid risk)",
    "Depression screening — PPT often misdiagnosed as postpartum depression",
  ];

  addTwoCols(s, left, right, 1.0, 12.5);
  addSource(s, "Berek & Novak's Gynecology (block 10, p. 1994+); Tietz Lab Medicine 7e; Creasy & Resnik's MFM");
}


// ════════════════════════════════════════════════════════════════
// SECTION DIVIDER — HEART
// ════════════════════════════════════════════════════════════════
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    fontSize: 13, color: LIGHT_GRAY, align: "center", fontFace: "Calibri",
  });
}


// ════════════════════════════════════════════════════════════════
// SLIDE 13 — CARDIOVASCULAR CHANGES & RISK STRATIFICATION
// ════════════════════════════════════════════════════════════════
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  const left = [
    "## Hemodynamic Changes in Pregnancy",
    "Plasma volume ↑ 40–50% (peaks ~32 wks)",
    "Cardiac output ↑ 30–50% (↑ in T1, peaks T2)",
    "  - Heart rate ↑ 10–20 bpm",
    "  - Stroke volume ↑",
    "SVR ↓ 20% (progesterone-mediated vasodilation)",
    "Systolic BP ↓ ~10 mmHg; diastolic ↓ ~10–20 mmHg",
    "Nadir at 20 weeks; rises toward pre-pregnancy levels at term",
    "Aortocaval compression by uterus (supine) → ↓ venous return",
    "## Echocardiographic Changes (Normal in Pregnancy)",
    "All 4 chambers enlarge (LV dimensions may exceed normal)",
    "LVEF preserved (normal to slightly ↑)",
    "Mild-moderate tricuspid regurgitation (common, normal)",
    "Pericardial effusion (small, physiological)",
  ];

  const right = [
    "## mWHO Classification (Modified WHO)",
    "Class I: No detectable increased risk (small ASD/VSD, repaired lesions)",
    "Class II: Small increased risk (unrepaired ASD/VSD, ToF repaired)",
    "Class IIl: Significantly increased risk (moderate LV dysfunction)",
    "  - mWHO II-III: requires specialist care",
    "Class III: High risk (mechanical valve, moderate-severe systemic dysfunction)",
    "Class IV: EXTREMELY HIGH risk — pregnancy contraindicated",
    "  - Pulmonary arterial hypertension",
    "  - Severe systemic ventricular dysfunction (EF <30%)",
    "  - Severe mitral or aortic stenosis",
    "  - Marfan with aorta >45 mm; DORV with above features",
    "## CARPREG II Score (predictors of cardiac events)",
    "Prior cardiac events / arrhythmia (+3)",
    "Baseline NYHA III-IV or cyanosis (+3)",
    "Mechanical valve (+3), High-risk valvular lesion (+3)",
    "Pulmonary hypertension (+2), Coronary artery disease (+2)",
    "High-risk aortopathy (+2), No prior cardiac intervention (+1)",
    "Late pregnancy assessment (+1)",
  ];

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  addSource(s, "Braunwald's Heart Disease 2-Vol (block 14, p. 776–850); Creasy & Resnik's MFM (block 13)");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 14 — PERIPARTUM CARDIOMYOPATHY (PPCM)
// ════════════════════════════════════════════════════════════════
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  addTitle(s, "Peripartum Cardiomyopathy (PPCM)", 0.2, "E07070");
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  const left = [
    "## Definition (Sliwa/ESC 2010)",
    "HF with LVEF <45% (or new fall of ≥10%)",
    "Last month of pregnancy OR within 5 months postpartum",
    "No pre-existing structural heart disease",
    "No identifiable cause for cardiomyopathy",
    "## Epidemiology",
    "Incidence: 1 in 1,000–4,000 (USA); higher in Nigeria, Haiti",
    "Higher risk: African descent, twin pregnancy, multiparty",
    "Advanced maternal age, preeclampsia, tocolytic use",
    "## Pathophysiology",
    "Antiangiogenic state: sFlt-1 ↑ (cleaves VEGF & PlGF)",
    "Prolactin cleavage → 16kDa fragment: vasoconstrictive, pro-apoptotic",
    "Oxidative stress → cathepsin D activation",
    "Genetic predisposition (TTN truncating variants)",
    "Inflammatory cytokines (TNF-α, IL-6, CRP elevated)",
  ];

  const right = [
    "## Clinical Features",
    "Dyspnea on exertion, orthopnea, PND",
    "Peripheral edema (may mimic normal pregnancy)",
    "S3 gallop, new MR murmur, basal crepitations",
    "Palpitations / arrhythmia; embolic events",
    "## Investigations",
    "ECG: sinus tachycardia, non-specific ST-T changes, BBB",
    "Echo: dilated LV, LVEF <45%, LV thrombus",
    "BNP/NT-proBNP: elevated (best marker of severity)",
    "CXR: cardiomegaly, pulmonary venous congestion",
    "## Management",
    "HF treatment: diuretics (furosemide), β-blockers (metoprolol)",
    "ACE inhibitors/ARBs: CONTRAINDICATED during pregnancy",
    "Post-delivery: start ACEI/ARB; add aldosterone antagonist",
    "Bromocriptine (dopamine agonist): blocks prolactin → may improve EF",
    "  - 2.5 mg BID for 2 wks; do not breastfeed",
    "Anticoagulation: LMWH during pregnancy; warfarin postpartum",
    "LVAD / heart transplant: for refractory cases",
    "## Prognosis",
    "Recovery (EF ≥50%): 50–70% within 6–12 months",
    "Recurrence in subsequent pregnancy: high — counsel against",
  ];

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  addSource(s, "Braunwald's Heart Disease (block 14, p. 1100+); Creasy & Resnik's MFM (block 13); Fuster & Hurst's Heart 15e");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 15 — VALVULAR HEART DISEASE IN PREGNANCY
// ════════════════════════════════════════════════════════════════
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  const left = [
    "## General Principles",
    "Regurgitant lesions (MR, AR): well-tolerated (↓ SVR helps)",
    "Stenotic lesions (MS, AS): poorly tolerated (↑ CO stresses fixed orifice)",
    "Rheumatic heart disease: still commonest in developing countries",
    "## Mitral Stenosis (MS) — Most Dangerous",
    "↑ Cardiac output → ↑ LA pressure → pulmonary edema",
    "Risk highest: T2–T3 (peak CO) and postpartum",
    "Symptoms: dyspnea, orthopnea, AF, hemoptysis",
    "mWHO III (moderate MS, MVA 1.0–1.5 cm²) to IV (<1.0 cm²)",
    "Management:",
    "  - β-blocker (reduce HR, prolong diastolic filling)",
    "  - Diuretics for pulmonary congestion",
    "  - Anticoagulation if AF or prior embolism",
    "  - Percutaneous mitral valvuloplasty (PTMC): preferred if severe",
    "  - CS delivery if MS severe + hemodynamic compromise",
  ];

  const right = [
    "## Aortic Stenosis (AS)",
    "Congenital bicuspid aortic valve commonest cause in young",
    "Severe AS (MVA <1.5 cm²): mWHO III–IV",
    "Risk: fixed CO → syncope, angina, sudden cardiac death",
    "Valvuloplasty or Ross procedure may be needed before pregnancy",
    "## Mitral Regurgitation (MR)",
    "Usually well-tolerated; vasodilation helps",
    "Acute MR (papillary muscle dysfunction) poorly tolerated",
    "Diuretics for volume overload; vasodilators post-delivery",
    "## Mechanical Prosthetic Valves",
    "Highest thrombotic risk in pregnancy (hypercoagulable state)",
    "Warfarin embryopathy: weeks 6–12 (nasal hypoplasia, stippled epiphyses)",
    "Options: warfarin throughout (best for valve, worst for fetus)",
    "LMWH in T1 → warfarin T2/T3 → LMWH near term",
    "UFH intrapartum → restart warfarin postpartum",
    "## Infective Endocarditis",
    "Rare but high mortality in pregnancy (20–30%)",
    "Organisms: Streptococcus, Staphylococcus",
    "IV antibiotics; surgery if refractory (carries fetal risk)",
  ];

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  addSource(s, "Braunwald's Heart Disease (block 14); Fuster & Hurst's The Heart 15e (block 19)");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 16 — ARRHYTHMIAS, CONGENITAL HEART DISEASE & PULMONARY HTN
// ════════════════════════════════════════════════════════════════
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  divider(s, 0.87, "E07070");

  const left = [
    "## Arrhythmias in Pregnancy",
    "Physiological: sinus tachycardia, occasional ectopics",
    "SVT (AVNRT): commonest; Valsalva, adenosine (safe)",
    "AF/Flutter: consider maternal/fetal cardioversion if unstable",
    "VT: IV lidocaine or procainamide; cardioversion if required",
    "Drug safety: β-blockers (metoprolol), digoxin, adenosine safe",
    "Amiodarone: avoid (fetal hypothyroidism, growth restriction)",
    "Electrophysiology: defer to post-pregnancy; use nonfluoroscopic if urgent",
    "## Congenital Heart Disease (CHD)",
    "Most common cardiac condition in pregnancy (high-income countries)",
    "Offspring CHD risk: 3–10% (vs 1% general population)",
    "Fetal echo at 18–22 weeks in all CHD mothers",
    "## ASD / VSD",
    "Small/moderate: usually well-tolerated",
    "Large (unrepaired): risk of Eisenmenger syndrome (mWHO IV)",
    "## Tetralogy of Fallot (Repaired)",
    "Residual PR, RVOTO: generally mWHO II–III",
    "Monitor RV function; RVOTO: anesthesia challenge",
  ];

  const right = [
    "## Eisenmenger Syndrome / PAH",
    "mWHO CLASS IV — pregnancy CONTRAINDICATED",
    "Mortality: 30–50% in pregnancy",
    "PAH (pulmonary arterial hypertension): equally dangerous",
    "If pregnant: ICU delivery, caesarean, multidisciplinary",
    "Prostacyclins (IV epoprostenol) may be used in extremis",
    "## Marfan Syndrome",
    "Risk: aortic dissection (↑ CO + estrogen weakens aorta)",
    "Aortic root >45 mm: pregnancy contraindicated",
    "40–45 mm: close imaging surveillance every 4–8 wks",
    "β-blockers throughout (atenolol avoided — fetal IUGR; use propranolol/metoprolol)",
    "## Transposition of Great Arteries (TGA)",
    "Repaired Mustard/Senning: RV is systemic → decompensates with ↑ preload",
    "Arterial switch repair: better outcome",
    "## Single Ventricle / Fontan Circulation",
    "Very high risk; mWHO III–IV",
    "Low-flow state; hepatic congestion; thrombosis risk",
    "Anticoagulation, close surveillance, specialized centers",
  ];

  addTwoCols(s, left, right, 1.0, 12.5);
  addSource(s, "Braunwald's Heart Disease (block 14); Fuster & Hurst's Heart 15e; Barash Clinical Anesthesia 9e; Creasy & Resnik's MFM");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 17 — DRUG SAFETY & MULTIDISCIPLINARY MANAGEMENT
// ════════════════════════════════════════════════════════════════
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  addTitle(s, "Drug Safety & Multidisciplinary Management in Pregnancy", 0.2, GOLD);
  divider(s, 0.87, GOLD);

  const left = [
    "## Cardiovascular Drugs — Safety Summary",
    "SAFE in pregnancy:",
    "  - β-blockers (metoprolol, propranolol, labetalol)",
    "  - Digoxin, adenosine, heparin (LMWH/UFH)",
    "  - Nifedipine, hydralazine (antihypertensives)",
    "  - Furosemide (short-term), methyldopa",
    "CONTRAINDICATED:",
    "  - ACE inhibitors / ARBs (nephrotoxic, teratogenic)",
    "  - Atenolol (fetal growth restriction)",
    "  - Aldosterone antagonists (spironolactone, eplerenone)",
    "  - Statins (teratogenic in animal models)",
    "  - Direct oral anticoagulants (DOACs) — fetal harm",
    "  - Bosentan (endothelin antagonist — teratogenic)",
    "  - Amiodarone (fetal hypothyroidism)",
    "  - Warfarin T1 (embryopathy) & near term (fetal hemorrhage)",
  ];

  const right = [
    "## Thyroid Drugs — Safety",
    "PTU: T1 (hepatotoxicity risk to mother)",
    "Methimazole: T2–T3 (avoid T1 — aplasia cutis risk)",
    "Levothyroxine: safe throughout; dose ↑ 25–50% early",
    "Iodine supplementation: essential (avoid excess)",
    "Radioiodine (I-131): ABSOLUTELY contraindicated",
    "## Multidisciplinary Pregnancy Heart Team",
    "Cardiologist (cardiac subspecialist)",
    "Maternal-Fetal Medicine (MFM) specialist",
    "Obstetric anesthesiologist",
    "Hematologist (anticoagulation)",
    "Neonatologist (fetal monitoring & delivery planning)",
    "Geneticist (CHD, Marfan, Wilson's)",
    "## Delivery Planning",
    "Low-risk cardiac: vaginal delivery preferred",
    "High-risk: multidisciplinary team delivery plan",
    "Epidural analgesia: preferred (reduces cardiac work)",
    "Avoid sudden hemodynamic shifts (slow SVR changes)",
    "Postpartum: critical period — fluid shifts, ↑ preload",
    "6-week postpartum review mandatory for ALL cardiac patients",
  ];

  addTwoCols(s, left, right, 1.0, 12);
  addSource(s, "Braunwald's Heart Disease (block 14, p. 1002–1010); Barash Clinical Anesthesia 9e; ATA Guidelines 2017");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 18 — COMPARISON TABLE: Key Liver Disorders
// ════════════════════════════════════════════════════════════════
{
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  topBar(s, "4CAF82");

  addTitle(s, "Comparison: Key Liver Disorders Unique to Pregnancy", 0.2, "4CAF82");
  divider(s, 0.87, "4CAF82");

  const headers = ["Feature", "ICP", "HELLP", "AFLP", "Pre-eclampsia Liver"];
  const rows2 = [
    ["Trimester", "T2–T3", "T2–T3", "T3 (>30 wks)", "T2–T3"],
    ["Incidence", "0.1–1.5%", "0.2–0.8%", "1:7,000–20,000", "5–8% of preg"],
    ["HTN/Proteinuria", "No", "Yes (80%)", "50% (concurrent)", "Yes (hallmark)"],
    ["Pruritus", "Yes (hallmark)", "No", "Mild/none", "No"],
    ["Jaundice", "10–25%", "Mild", "Yes (moderate)", "Mild"],
    ["AST/ALT", "Mild ↑", "Marked ↑", "Moderate ↑", "Moderate ↑"],
    ["Platelets", "Normal", "↓↓", "↓", "↓"],
    ["Hypoglycemia", "No", "No", "YES (hallmark)", "No"],
    ["DIC", "No", "Yes (severe)", "YES (hallmark)", "Severe cases"],
    ["Biopsy", "Normal/minimal", "Periportal necrosis", "Microvesicular fat", "Fibrin deposits"],
    ["Treatment", "UDCA, delivery ≥36w", "Delivery", "URGENT DELIVERY", "Delivery, MgSO4"],
  ];

  const colW2 = [2.2, 2.45, 2.35, 2.6, 3.4];
  const colX2 = [0.3, 2.55, 5.0, 7.4, 10.05];

  // headers
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    s.addText(h, { x: colX2[j] + 0.05, y: 1.02, w: colW2[j] - 0.1, h: 0.44, fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  rows2.forEach((row, i) => {
    row.forEach((cell, j) => {
      const y = 1.5 + i * 0.52;
      s.addShape(pres.ShapeType.rect, { x: colX2[j], y, w: colW2[j] - 0.05, h: 0.49, fill: { color: i % 2 === 0 ? "1B3A2E" : "152D23" }, line: { color: TEAL, width: 0.3 } });
      s.addText(cell, { x: colX2[j] + 0.05, y: y + 0.03, w: colW2[j] - 0.1, h: 0.44, fontSize: j === 0 ? 11 : 10.5, bold: j === 0, color: j === 0 ? GOLD : CREAM, fontFace: "Calibri", valign: "middle", margin: 0 });
    });
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  addSource(s, "Sleisenger & Fordtran's; Goldman-Cecil Medicine; Creasy & Resnik's MFM; Yamada's Gastroenterology");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 19 — SUMMARY / KEY TAKE-HOME POINTS
// ════════════════════════════════════════════════════════════════
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  topBar(s, GOLD);
  bottomBar(s, GOLD);

  addTitle(s, "Key Take-Home Points", 0.2, GOLD);
  divider(s, 0.87, GOLD);

  const points = [
    "## LIVER",
    "HELLP = Hemolysis + ↑LFTs + ↓Platelets; 0.2–0.8% pregnancies; DELIVER urgently",
    "AFLP = microvesicular fat + liver failure + DIC; LCHAD mutation; treat hypoglycemia; DELIVER immediately",
    "ICP = bile acids ↑ + pruritus; fetal stillbirth risk >40 μmol/L; UDCA first-line",
    "HEV in T3: 20–30% mortality; no specific antiviral",
    "## THYROID",
    "TSH normal ranges are TRIMESTER-SPECIFIC; use gestational reference ranges",
    "Hypothyroidism: LT4 dose ↑ 25–50% as soon as pregnancy diagnosed; target TSH T1 <2.5",
    "PTU preferred T1; switch to methimazole in T2; radioiodine CONTRAINDICATED",
    "Graves TRAb → fetal/neonatal hyperthyroidism (2–10%); monitor fetal heart rate & thyroid by USS",
    "Postpartum thyroiditis: TPO-Ab+, triphasic; often misdiagnosed as postpartum depression",
    "## HEART",
    "mWHO IV (PAH, severe systemic ventricular dysfunction, severe stenosis): CONTRAINDICATED for pregnancy",
    "PPCM: LVEF <45% last month/5 months postpartum; bromocriptine + standard HF therapy post-delivery",
    "Mitral stenosis most dangerous stenotic lesion; β-blocker + PTMC if severe",
    "ACE inhibitors, ARBs, statins, DOACs, atenolol: ALL contraindicated in pregnancy",
    "Multidisciplinary Pregnancy Heart Team: cardiologist + MFM + anesthesiologist + neonatologist",
  ];

  addBullets(s, points, 0.5, 1.0, 12.3, 12.5, CREAM);
  addSource(s, "Sources: Braunwald's Heart Disease | Sleisenger & Fordtran's | Harrison's 22e | Creasy & Resnik's | Berek & Novak's | Fuster & Hurst's Heart 15e");
}


// ════════════════════════════════════════════════════════════════
// SLIDE 20 — REFERENCES
// ════════════════════════════════════════════════════════════════
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  bottomBar(s, GOLD);

  addTitle(s, "References & Recommended Reading", 0.2, GOLD);
  divider(s, 0.87, TEAL);

  const refs = [
    "1. Sleisenger MH, Feldman M. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 11th ed. Elsevier, 2021. (Chapter 40: Liver Disease in Pregnancy)",
    "2. Libby P, et al. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 12th ed. Elsevier, 2022. (Chapter 92: Pregnancy & Cardiovascular Disease)",
    "3. Creasy RK, Resnik R. Creasy & Resnik's Maternal-Fetal Medicine: Principles & Practice, 8th ed. Elsevier, 2022.",
    "4. Berek JS, et al. Berek & Novak's Gynecology, 16th ed. Lippincott, 2020. (Chapter 35: Thyroid Disorders in Pregnancy)",
    "5. Kasper DL, et al. Harrison's Principles of Internal Medicine, 22nd ed. McGraw-Hill, 2025.",
    "6. Fuster V, et al. Fuster & Hurst's The Heart, 15th ed. McGraw-Hill, 2022.",
    "7. Yamada T, et al. Yamada's Textbook of Gastroenterology, 7th ed. Wiley-Blackwell, 2022.",
    "8. Alexander EK, et al. 2017 Guidelines of the ATA for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017;27(3):315–389.",
    "9. Sliwa K, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the ESC Working Group. Eur J Heart Fail. 2010;12:767–778.",
    "10. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019;133(1):e1–e25.",
    "11. Tietz CA. Tietz Textbook of Laboratory Medicine, 7th ed. Elsevier, 2023. (Chapter: Thyrotoxicosis in Pregnancy)",
    "12. Barash PG, et al. Barash, Cullen & Stoelting's Clinical Anesthesia, 9th ed. Lippincott, 2023.",
  ];

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      fontFace: "Calibri", margin: 0, valign: "top",
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// ════════════════════════════════════════════════════════════════
// WRITE FILE
// ════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/pregnancy-pathology-ppt/Pathological_Disorders_in_Pregnancy.pptx" })
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