const pptxgen = require("pptxgenjs");
const fs = require("fs");

// Load pre-fetched images
const imgs = JSON.parse(fs.readFileSync("images.json"));
const smearImg = imgs[0].base64;       // microcytic hypochromic smear
const thalFlowImg = imgs[1].base64;    // thalassemia screening flowchart

// ─── PALETTE ────────────────────────────────────────────────
// Medical deep navy/crimson theme
const C = {
  navy:     "0D1B3E",   // dominant dark
  crimson:  "C0392B",   // accent red (blood / medical)
  teal:     "1A6B7C",   // secondary
  gold:     "D4A017",   // highlight
  white:    "FFFFFF",
  lightGray:"F4F6F9",
  midGray:  "8C9BAB",
  darkGray: "2C3E50",
  green:    "1E8449",
  orange:   "D35400",
  purple:   "6C3483",
};

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "OBGYN Seminar";
pres.title = "Anemia in Pregnancy";

// ─── HELPER FUNCTIONS ────────────────────────────────────────

// Standard slide with navy header bar
function makeSlide(titleText, sectionTag) {
  let s = pres.addSlide();
  // Full background
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{ color: C.lightGray }, line:{ color: C.lightGray } });
  // Top header bar
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  // Crimson left accent stripe
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  // Bottom footer
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  s.addText("Anemia in Pregnancy  |  OBGYN Seminar", { x:0.2, y:5.3, w:7, h:0.325, fontSize:8, color:C.midGray, valign:"middle", margin:0 });
  s.addText("Source: Creasy & Resnik / Goldman-Cecil / NFHS-5", { x:5, y:5.3, w:4.8, h:0.325, fontSize:7, color:C.midGray, align:"right", valign:"middle", margin:0 });

  // Title
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  return s;
}

// Dark "chapter divider" slide
function makeDivider(label, sub) {
  let s = pres.addSlide();
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}

// Stat card
function addStatCard(s, x, y, w, h, value, label, color) {
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}

// Colored info box
function addBox(s, x, y, w, h, title, body, titleColor, bgColor) {
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}

// bullet list helper - returns array for addText
function bullets(items, opts) {
  opts = opts || {};
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  }));
}

// ════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{ color: C.navy }, line:{ color: C.navy } });
  // Decorative circles
  s.addShape(pres.shapes.OVAL, { x:7.5, y:-0.5, w:4, h:4, fill:{ color: C.teal, transparency:75 }, line:{ color: C.teal, transparency:75 } });
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  // Left accent
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  // Gold bar under title
  s.addShape(pres.shapes.RECTANGLE, { x:0.5, y:2.85, w:5, h:0.06, fill:{ color: C.gold }, line:{ color: C.gold } });

  s.addText("ANEMIA IN PREGNANCY", { x:0.5, y:1.1, w:8, h:1.3, fontSize:36, bold:true, color:C.white, charSpacing:3 });
  s.addText("Comprehensive Seminar for OBG Residents", { x:0.5, y:2.45, w:8, h:0.45, fontSize:16, color:C.gold, italic:true });
  s.addText([
    { text: "Department of Obstetrics & Gynaecology  ", options:{fontSize:11, color:C.midGray} },
    { text: "\nIndia | NFHS-5 | WHO 2024 | Creasy & Resnik · Goldman-Cecil · Harrison's", options:{fontSize:9.5, color:C.midGray} }
  ], { x:0.5, y:3.1, w:8.5, h:0.9 });
  s.addText([
    { text: "52.2%", options:{fontSize:38, bold:true, color:C.crimson} },
    { text: "  of pregnant women in India are anemic", options:{fontSize:13, color:C.white} }
  ], { x:0.5, y:4.1, w:9, h:0.8 });
}

// ════════════════════════════════════════════════════════════
// SLIDE 2 — TABLE OF CONTENTS
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("Table of Contents", "OVERVIEW");
  const sections = [
    ["01", "Definition (WHO)", C.crimson],
    ["02", "Epidemiology & India Burden", C.teal],
    ["03", "Classification of Causes", C.purple],
    ["04", "Effects on Mother & Fetus", C.orange],
    ["05", "Iron Deficiency Anemia", C.crimson],
    ["06", "Megaloblastic Anemia", C.teal],
    ["07", "Hemolytic Anemias", C.orange],
    ["08", "Aplastic Anemia", C.purple],
    ["09", "Thalassemias", C.green],
    ["10", "Sickle Cell Disease", C.crimson],
    ["11", "Anemia of Chronic Disease", C.teal],
    ["12", "Management Flowchart", C.navy],
  ];
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    const y = gy + row*(bh + 0.07);
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    s.addShape(pres.shapes.RECTANGLE, { x, y, w:0.5, h:bh, fill:{ color: sec[2] }, line:{ color: sec[2] } });
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    s.addText(sec[1], { x: x+0.58, y, w: bw-0.65, h:bh, fontSize:11, color:C.darkGray, valign:"middle", margin:0 });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 3 — DEFINITION
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("1. Definition — WHO", "DEFINITION");
  // Quote box
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:0.85, w:9.6, h:0.88, fill:{ color: C.navy }, line:{ color: C.navy } });
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:0.85, w:0.12, h:0.88, fill:{ color: C.gold }, line:{ color: C.gold } });
  s.addText('"Anemia is a condition where the number of RBCs (and thus Hb concentration) is insufficient to meet the body\'s physiological needs."  — WHO', {
    x:0.45, y:0.85, w:9.2, h:0.88, fontSize:11, color:C.white, italic:true, valign:"middle"
  });

  // WHO threshold table
  s.addText("WHO / CDC Operative Hb Thresholds in Pregnancy", { x:0.2, y:1.85, w:5.6, h:0.32, fontSize:10, bold:true, color:C.navy });
  const tRows = [
    ["Trimester / Period", "Hb Threshold (g/dL)", "Haematocrit (%)"],
    ["1st Trimester",      "< 11.0",               "< 33%"],
    ["2nd Trimester",      "< 10.5",               "< 32%"],
    ["3rd Trimester",      "< 11.0",               "< 33%"],
    ["Postpartum",         "< 10.0",               "< 30%"],
  ];
  s.addTable(tRows, {
    x:0.2, y:2.2, w:5.5, h:2.7,
    colW:[2.4, 1.8, 1.3],
    fontSize:9.5,
    border:{ type:"solid", color:"D0D0D0", pt:0.5 },
    fill: C.white,
    fontFace:"Calibri",
    align:"center",
    valign:"middle",
  });

  // Severity classification
  s.addText("WHO Severity Classification (2024)", { x:5.85, y:1.85, w:3.9, h:0.32, fontSize:10, bold:true, color:C.navy });
  const sevRows = [
    ["Category",    "Hb (g/dL)"],
    ["Normal",      "≥ 11.0"],
    ["Mild",        "10.0 – 10.9"],
    ["Moderate",    "7.0 – 9.9"],
    ["Severe",      "< 7.0"],
    ["Life-threat.", "< 5.0"],
  ];
  const sevColors = [C.navy, C.green, C.gold, C.orange, C.crimson, "7D0000"];
  s.addTable(sevRows, {
    x:5.85, y:2.2, w:3.9, h:2.7,
    colW:[2.2,1.7],
    fontSize:9.5,
    border:{ type:"solid", color:"D0D0D0", pt:0.5 },
    fontFace:"Calibri",
    align:"center",
    valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 4 — EPIDEMIOLOGY INDIA
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("2. Epidemiology — India Burden (NFHS-5, 2019-21)", "EPIDEMIOLOGY");
  // Big stat cards
  const cards = [
    ["52.2%",  "Pregnant women\nwith anemia (India)", C.crimson],
    ["1.4%",   "Severe anemia\n(Hb <7 g/dL)", "7D0000"],
    ["57%",    "Women of repro.\nage anemic (NFHS-5)", C.orange],
    ["63.1%",  "Bihar — highest\nstate burden", C.teal],
    ["71.4%",  "Ladakh — highest\nUT burden", C.purple],
    ["81.5%",  "Udalgiri (Assam)\nworst district", C.navy],
  ];
  cards.forEach((c,i) => {
    const col = i%3, row = Math.floor(i/3);
    addStatCard(s, 0.2 + col*3.22, 0.9 + row*1.45, 3.0, 1.28, c[0], c[1], c[2]);
  });
  // Risk factors
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:3.55, w:9.6, h:1.62, fill:{ color: C.white }, line:{ color: C.teal, pt:1 } });
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:3.55, w:9.6, h:0.3, fill:{ color: C.teal }, line:{ color: C.teal } });
  s.addText("Key Risk Factors — India (NFHS-5 Logistic Regression)", { x:0.3, y:3.55, w:9, h:0.3, fontSize:9.5, bold:true, color:C.white, valign:"middle", margin:2 });
  const rfItems = [
    "No formal education → aOR 1.41    |    Poorest wealth quintile → aOR 1.69",
    "Tobacco / smoking / alcohol → aOR 1.39    |    Short birth interval → higher risk",
    "Adolescent pregnancy (61.5%)    |    Scheduled Tribes (59.3%)    |    Eastern India (62.1%)",
    "Vegetarian diet (low heme-iron bioavailability)    |    High multiparity    |    Hookworm / malaria endemic zones",
  ];
  s.addText(rfItems.map((r,i) => ({ text:r, options:{ bullet:{ type:"bullet" }, fontSize:8.8, color:C.darkGray, breakLine: i<rfItems.length-1 } })),
    { x:0.4, y:3.88, w:9.2, h:1.25 });
}

// ════════════════════════════════════════════════════════════
// SLIDE 5 — CAUSES CLASSIFICATION
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("3. Classification of Causes", "CAUSES");
  // Two columns: Hereditary | Acquired
  addBox(s, 0.2, 0.85, 4.6, 4.35, "HEREDITARY (Genetic)", [
    "Hemoglobinopathies:",
    "  • Sickle cell disease (SS, SC, S-β thal)",
    "  • Sickle cell trait (AS)",
    "  • Hb C, Hb E, Hb D Punjab",
    "",
    "Thalassemias:",
    "  • α-Thalassemia (gene deletions)",
    "  • β-Thalassemia (point mutations)",
    "  • HbE + β-thal (common in NE India)",
    "",
    "RBC Enzyme Defects:",
    "  • G6PD deficiency (X-linked recessive)",
    "",
    "RBC Membrane Disorders:",
    "  • Hereditary spherocytosis (AD)",
    "  • Hereditary elliptocytosis",
  ].join("\n"), C.purple, C.white);
  addBox(s, 5.05, 0.85, 4.75, 4.35, "ACQUIRED", [
    "Nutritional (MOST COMMON in India):",
    "  • Iron deficiency anemia (IDA) — #1",
    "  • Folate deficiency (megaloblastic) — #2",
    "  • Vitamin B12 deficiency",
    "",
    "Physiological (Dilutional) — Normal",
    "",
    "Acute Blood Loss: APH, PPH, rupture",
    "",
    "Anemia of Chronic Disease (ACD):",
    "  • TB, Malaria, HIV, chronic renal disease",
    "",
    "Hemolytic (Acquired):",
    "  • AIHA (warm/cold), HELLP, TTP/HUS",
    "",
    "Bone Marrow Failure:",
    "  • Aplastic anemia, Leukemia",
  ].join("\n"), C.teal, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 6 — EFFECTS ON MOTHER
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("4a. Effects on Mother", "MATERNAL EFFECTS");
  const boxes = [
    ["ANTENATAL", ["High-output cardiac failure (severe)", "Tachycardia, palpitations, dyspnoea", "Increased infection risk (UTI, TB, pneumonia)", "Pre-eclampsia risk ↑ (SCD)", "Preterm labour / PROM"], C.teal],
    ["INTRAPARTUM", ["Poor uterine contractions (iron def.)", "Prolonged labour (fatigue)", "Poor tolerance of blood loss", "Increased need for blood transfusion", "Sickle crises during labour"], C.orange],
    ["POSTPARTUM / SURGICAL", ["PPH — primary cause of maternal death in India", "Poor wound healing, SSI ↑", "Puerperal sepsis (immune compromise)", "Postpartum depression (iron def.)", "Failure of lactation, prolonged hospital stay"], C.crimson],
  ];
  boxes.forEach((b,i) => {
    addBox(s, 0.2 + i*3.27, 0.85, 3.1, 3.4, b[0], b[1].map(x=>"• "+x).join("\n"), b[2], C.white);
  });
  // Key stat banner
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:4.35, w:9.6, h:0.7, fill:{ color: C.navy }, line:{ color: C.navy } });
  s.addText([
    { text: "Maternal mortality RR = 3.5", options:{fontSize:13, bold:true, color:C.crimson} },
    { text: "  with severe anemia (Hb <5 g/dL) — Asia, Africa, Latin America (Creasy & Resnik)", options:{fontSize:10, color:C.white} }
  ], { x:0.4, y:4.35, w:9.2, h:0.7, valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 7 — EFFECTS ON FETUS
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("4b. Effects on Fetus & Neonate", "FETAL EFFECTS");
  const fRows = [
    ["Maternal Hb", "Fetal / Neonatal Risk"],
    ["Hb 9 – 11 g/dL (Mild)", "Generally good outcome"],
    ["Hb 7 – 9 g/dL (Moderate)", "↑ Preterm birth, ↑ Low birth weight"],
    ["Hb < 7 g/dL (Severe)", "↑ FGR/SGA, ↑ Perinatal death"],
    ["Hb < 6 g/dL (Very severe)", "Abnormal fetal oxygenation, non-reassuring FHR, stillbirth"],
    ["Hb > 14.5 g/dL (Too high!)", "Paradox: poor placentation → SGA, stillbirth (inadequate plasma expansion)"],
  ];
  s.addTable(fRows, {
    x:0.2, y:0.85, w:9.6, h:2.4,
    colW:[3.4,6.2],
    fontSize:9.5,
    border:{ type:"solid", color:"D0D0D0", pt:0.5 },
    fontFace:"Calibri",
    align:"left",
    valign:"middle",
  });
  // Bottom boxes
  const fboxes = [
    ["Preterm Birth", "Significant association with anemia early in pregnancy — confirmed by meta-analyses (Creasy & Resnik)", C.orange],
    ["Neonatal Iron Deficiency", "Ferritin <25th percentile → long-term ABNORMAL NEUROLOGIC FUNCTION, cognitive delays, language deficits", C.crimson],
    ["Neural Tube Defects", "Periconceptional folate deficiency — 400 μg/day supplementation mandatory; 5 mg for high-risk women", C.teal],
    ["Delayed Cord Clamping", "WHO + ACOG recommend 30-60 second delay — significantly increases neonatal iron stores", C.green],
  ];
  fboxes.forEach((b,i) => {
    addBox(s, 0.2 + i*2.42, 3.35, 2.26, 1.68, b[0], b[1], b[2], C.white);
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 8 — DIVIDER: PHYSIOLOGICAL
// ════════════════════════════════════════════════════════════
makeDivider("PHYSIOLOGICAL ANEMIA OF PREGNANCY", "Normal Adaptive Hemodilution — Understanding the Baseline");

// ════════════════════════════════════════════════════════════
// SLIDE 9 — PHYSIOLOGICAL ANEMIA
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("5A. Physiological (Dilutional) Anemia", "PHYSIOLOGICAL");
  // Volume change table
  s.addText("Normal Blood Volume Changes", { x:0.2, y:0.85, w:4.8, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Parameter", "Change"],
    ["Total blood volume", "↑ 40–45%"],
    ["Plasma volume", "↑ 47%"],
    ["RBC mass", "↑ 17–20%"],
    ["Net effect", "Relative hemodilution"],
    ["Hb nadir at", "28–34 weeks"],
  ], { x:0.2, y:1.18, w:4.8, h:2.15, colW:[2.8,2.0], fontSize:9.5, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"center", valign:"middle" });

  // Key distinguishing features
  addBox(s, 0.2, 3.4, 4.8, 1.52, "Key Points — Physiological Anemia", [
    "• MCV and MCHC do NOT change (key distinction from IDA)",
    "• Hb falls because plasma rises faster than RBC mass",
    "• Protective: reduces blood viscosity → improves uteroplacental flow",
    "• Ferritin: NORMAL",
    "• NO treatment required — routine IFA supplementation continues",
  ].join("\n"), C.green, C.white);

  // Right column: IDA vs physio distinction
  addBox(s, 5.25, 0.85, 4.5, 4.07, "Physiological vs. IDA — Distinguish by:", [
    "Parameter          Physiol.    IDA",
    "─────────────────────────────",
    "MCV               NORMAL    ↓↓",
    "MCHC              NORMAL    ↓",
    "Ferritin           NORMAL    ↓ (<15)",
    "TIBC               NORMAL    ↑ (>400)",
    "% Sat              NORMAL    ↓ (<16%)",
    "Reticulocyte       Nl/mild ↑  ↓",
    "Symptoms          None      Pica, pallor",
    "",
    "⚠ Serial MCV + MCHC unchanged",
    "  = dilutional (reassuring)",
    "  Declining MCV + MCHC = IDA",
  ].join("\n"), C.teal, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 10 — DIVIDER IDA
// ════════════════════════════════════════════════════════════
makeDivider("IRON DEFICIENCY ANEMIA (IDA)", "Most Common — Accounts for >50% of all Anemia in Pregnancy");

// ════════════════════════════════════════════════════════════
// SLIDE 11 — IDA PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("5B. IDA — Iron Requirements & Pathophysiology", "IDA");
  // Iron requirements table
  s.addText("Iron Requirements in Pregnancy (Creasy & Resnik)", { x:0.2, y:0.85, w:5.5, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Purpose", "Average (mg)", "Range (mg)"],
    ["External iron loss", "170", "150–200"],
    ["Expand RBC mass", "450", "200–600"],
    ["Fetal iron needs", "270", "200–370"],
    ["Placenta & cord", "90", "30–170"],
    ["Blood loss at delivery", "150", "90–310"],
    ["TOTAL", "1130", "580–1340"],
  ], { x:0.2, y:1.18, w:5.4, h:2.6, colW:[2.8,1.3,1.3], fontSize:9.5, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"center", valign:"middle" });

  // Three stages boxes
  s.addText("3 Stages of Iron Deficiency", { x:0.2, y:3.85, w:5.4, h:0.3, fontSize:9.5, bold:true, color:C.navy });
  const stages = [
    ["Stage 1\nPre-latent", "↓ Ferritin\nStores depleted\nHb NORMAL", C.gold],
    ["Stage 2\nLatent", "↓ Serum Fe\n↑ TIBC\n↓ % Saturation\nHb still NORMAL", C.orange],
    ["Stage 3\nOvert IDA", "↓ Hb\n↓ MCV\nMicrocytic smear\nSymptoms appear", C.crimson],
  ];
  stages.forEach((st, i) => {
    const x = 0.2 + i*1.87;
    s.addShape(pres.shapes.RECTANGLE, { x, y:4.18, w:1.75, h:0.98, fill:{ color: st[2] }, line:{ color: st[2] } });
    s.addText(st[0], { x, y:4.18, w:1.75, h:0.3, fontSize:8, bold:true, color:C.white, align:"center", valign:"middle", margin:1 });
    s.addText(st[1], { x, y:4.5, w:1.75, h:0.66, fontSize:7.5, color:C.white, align:"center", valign:"top", margin:2 });
    if(i<2) s.addText("→", { x: x+1.77, y:4.5, w:0.1, h:0.5, fontSize:14, bold:true, color:C.crimson, valign:"middle" });
  });

  // Right column: key facts
  addBox(s, 5.85, 0.85, 3.9, 2.3, "Iron Balance in India", [
    "Daily requirement: 22–23 mg/day",
    "Average Indian diet provides: ~15 mg/day",
    "Only 10–15% non-heme iron absorbed",
    "Only 25–30% heme iron absorbed",
    "Vegetarian diets = predominantly non-heme iron",
    "Short inter-pregnancy interval depletes stores",
    "Hookworm infection: chronic GI blood loss (1 mL/day/worm)",
    "",
    "60% of women with ferritin <20 μg/L",
    "before pregnancy develop IDA by 20 wks",
  ].join("\n"), C.teal, C.white);
  addBox(s, 5.85, 3.3, 3.9, 1.85, "IDA Clinical Features", [
    "Fatigue, weakness, exertional dyspnoea",
    "PICA — pagophagia (ice), geophagia (clay/chalk)",
    "Restless legs syndrome",
    "Koilonychia (spoon nails) — chronic IDA",
    "Angular stomatitis, atrophic glossitis",
    "Pallor: conjunctiva, nails, tongue",
    "Soft systolic flow murmur (high-output)",
  ].join("\n"), C.crimson, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 12 — IDA INVESTIGATIONS + SMEAR IMAGE
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("5B. IDA — Laboratory Investigations", "IDA");
  // Peripheral smear image
  s.addImage({ data: smearImg, x:0.2, y:0.85, w:3.5, h:2.5 });
  s.addText("Peripheral smear: Microcytic hypochromic RBCs\nlarge central pallor, pencil cells, anisocytosis\n(Goldman-Cecil Medicine)", { x:0.2, y:3.38, w:3.5, h:0.75, fontSize:7.5, color:C.midGray, italic:true, align:"center" });

  // Iron studies comparison table
  s.addText("Iron Studies — Differential Diagnosis", { x:3.85, y:0.85, w:5.9, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Test", "IDA", "ACD", "Thalassemia"],
    ["Serum iron", "↓↓", "↓", "Normal/↑"],
    ["TIBC", "↑ (>400)", "↓", "Normal"],
    ["% Saturation", "↓ (<16%)", "↓ (<30%)", "Normal/↑"],
    ["Ferritin", "↓ (<15)", "↑ (>200)", "Normal/↑"],
    ["MCV", "↓ (<80)", "Normal/↓", "↓↓"],
    ["RDW", "↑ (>15%)", "Normal", "Normal"],
    ["Hb A2 (HPLC)", "Normal", "Normal", "↑ >3.5% (β)"],
  ], { x:3.85, y:1.18, w:5.9, h:2.9, colW:[2.1,1.2,1.2,1.4], fontSize:9, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"center", valign:"middle" });

  // Key tip box
  s.addShape(pres.shapes.RECTANGLE, { x:3.85, y:4.15, w:5.9, h:0.75, fill:{ color: C.gold }, line:{ color: C.gold } });
  s.addText([
    { text: "★  FERRITIN ", options:{fontSize:11, bold:true, color:C.navy} },
    { text: "is the MOST ACCURATE single test for IDA in pregnancy.  ", options:{fontSize:10, color:C.navy} },
    { text: "Ferritin <15 μg/L = diagnostic.  Ferritin is an acute-phase reactant — may be falsely elevated in infection; use <30 μg/L threshold if co-existing inflammation.", options:{fontSize:8.5, color:C.darkGray} }
  ], { x:4.0, y:4.15, w:5.6, h:0.75, valign:"middle" });

  // Mentzer index
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:4.15, w:3.5, h:0.75, fill:{ color: C.purple }, line:{ color: C.purple } });
  s.addText([
    { text: "Mentzer Index = MCV / RBC count\n", options:{fontSize:9.5, bold:true, color:C.white} },
    { text: "> 13 → IDA    |    < 13 → Thalassemia trait", options:{fontSize:9, color:C.white} }
  ], { x:0.25, y:4.15, w:3.4, h:0.75, valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 13 — IDA TREATMENT
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("5B. IDA — Treatment Protocol", "IDA TREATMENT");
  // Oral iron
  addBox(s, 0.2, 0.85, 4.7, 2.35, "ORAL IRON — First Line", [
    "Ferrous sulfate 325 mg = 65 mg elemental Fe (cheapest, standard)",
    "Ferrous gluconate 300 mg = 35 mg (better tolerated)",
    "Ferrous fumarate / ascorbate: alternatives",
    "",
    "Prophylaxis (WHO/NHM India): 60 mg elem Fe + 500 μg FA daily × 180 days",
    "Treatment dose: 100–200 mg elemental iron/day",
    "",
    "Take on EMPTY STOMACH + Vitamin C (↑ absorption)",
    "AVOID with: tea (↓90%), coffee (↓60%), calcium, antacids, high-fibre meals",
    "Alternate-day dosing: equally effective, fewer GI side effects (RCT data)",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.1, 0.85, 4.7, 2.35, "IV IRON — When Oral Fails/Insufficient", [
    "Indications: 3rd trimester, intolerance, malabsorption, severe IDA",
    "NOT used in 1st trimester",
    "",
    "Ferric Carboxymaltose: 1000 mg single dose — PREFERRED (no test dose)",
    "Iron Sucrose: 100–200 mg per session (multiple sessions; safe in India)",
    "Low-MW Iron Dextran: 1000 mg over 1 hr (requires test dose)",
    "",
    "Side effects: flushing, myalgia, hypophosphatemia (FCM)",
    "Anaphylaxis rare but serious (mainly high-MW dextran)",
    "IV iron superior to oral iron in pregnancy — multiple RCTs",
  ].join("\n"), C.crimson, C.white);

  // Blood transfusion
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:3.28, w:9.6, h:0.3, fill:{ color: C.navy }, line:{ color: C.navy } });
  s.addText("BLOOD TRANSFUSION", { x:0.25, y:3.28, w:9, h:0.3, fontSize:10, bold:true, color:C.gold, valign:"middle", margin:2 });
  s.addTable([
    ["Indication", "Threshold"],
    ["Antenatally symptomatic / cardiovascular compromise", "Any Hb"],
    ["Antenatal IDA — severe", "Hb < 6 g/dL"],
    ["Pre-operative (CS, etc.)", "Hb < 7–8 g/dL"],
    ["Active hemorrhage / PPH", "Clinical judgment — transfuse early"],
    ["Cardiac disease in pregnancy", "Hb < 10 g/dL"],
  ], { x:0.2, y:3.62, w:9.6, h:1.63, colW:[6.2,3.4], fontSize:9, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 14 — MEGALOBLASTIC ANEMIA
// ════════════════════════════════════════════════════════════
makeDivider("MEGALOBLASTIC ANEMIA", "2nd Most Common Nutritional Anemia — Folate & B12 Deficiency");

{
  let s = makeSlide("6. Megaloblastic Anemia — Pathophysiology & Features", "MEGALOBLASTIC");
  addBox(s, 0.2, 0.85, 4.7, 2.05, "Pathophysiology", [
    "Folate → Tetrahydrofolate (THF) via dihydrofolate reductase",
    "THF essential for thymidylate synthesis → DNA synthesis",
    "Without THF: cells enlarge but cannot divide → MEGALOBLASTS",
    "",
    "B12 deficiency → 'Folate trap': 5-methyl-THF trapped →",
    "  same end result as folate deficiency PLUS neurological damage",
    "  ↑ Homocysteine → thrombosis, NTD",
    "",
    "Folate needs ↑ 50% in pregnancy (fetal demand + cell turnover)",
    "Half-life serum folate only 3–5 weeks → deficiency develops quickly",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.1, 0.85, 4.7, 2.05, "Causes — India Context", [
    "FOLATE DEFICIENCY:",
    "  • Poor diet (most common in India)",
    "  • Folate antagonists: methotrexate, trimethoprim, phenytoin, valproate",
    "  • Malabsorption: celiac, IBD, tropical sprue, gastric bypass",
    "  • Multiple pregnancy, hemolytic anemias",
    "",
    "B12 DEFICIENCY (very common in India!):",
    "  • Vegetarian/vegan diet — no animal products",
    "  • Pernicious anemia (anti-intrinsic factor antibodies)",
    "  • Metformin (blocks B12 absorption)",
    "  • Crohn's disease / terminal ileal resection",
  ].join("\n"), C.purple, C.white);

  // Features comparison table
  s.addText("Folate vs. B12 Deficiency — Clinical Comparison", { x:0.2, y:3.0, w:9.6, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Feature", "Folate Deficiency", "B12 Deficiency"],
    ["Onset", "Rapid (weeks–months)", "Slow (years)"],
    ["Macrocytic anemia", "Yes", "Yes"],
    ["Hypersegmented neutrophils", "Yes", "Yes"],
    ["Glossitis / stomatitis", "Yes", "Yes"],
    ["Neurological symptoms", "ABSENT", "YES — SCD (dorsal & lateral columns)"],
    ["Neural tube defects (fetus)", "Yes — periconceptional", "Less direct association"],
    ["Homocysteine ↑", "Yes", "Yes"],
    ["MMA ↑", "NO", "YES — specific for B12 def."],
  ], { x:0.2, y:3.33, w:9.6, h:1.95, colW:[3.0,3.1,3.5], fontSize:8.8, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 15 — MEGALOBLASTIC TREATMENT
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("6. Megaloblastic Anemia — Investigations & Treatment", "MEGALOBLASTIC Rx");
  addBox(s, 0.2, 0.85, 4.7, 2.1, "Laboratory Investigations", [
    "CBC: ↑ MCV (>100 fL)",
    "Peripheral smear: Oval macrocytes + hypersegmented neutrophils (≥5 lobes)",
    "Serum folate: ↓ (<2.5 ng/mL) in folate def.",
    "RBC folate: more reliable (reflects long-term stores)",
    "Serum B12: ↓ (<200 pg/mL) in B12 def.",
    "Methylmalonic acid (MMA): ↑ — SPECIFIC for B12 def.",
    "Homocysteine: ↑ (both deficiencies)",
    "Anti-intrinsic factor antibodies: + in pernicious anemia (sensitivity 60%)",
    "Bone marrow: megaloblasts, giant metamyelocytes (rarely needed)",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.1, 0.85, 4.7, 2.1, "Treatment", [
    "FOLATE DEFICIENCY:",
    "  Prevention (ALL women): 400–500 μg/day pre-conception",
    "  High-risk (prior NTD, anticonvulsants, DM, obesity): 5 mg/day",
    "  NHM India IFA tablet: 100 mg Fe + 500 μg FA × 180 days",
    "  Treatment of folate def. anemia: Folic acid 5 mg/day orally",
    "",
    "B12 DEFICIENCY:",
    "  Dietary (vegetarian): Cyanocobalamin oral 1000–2000 μg/day",
    "  Pernicious anemia/malabsorption: IM cyanocobalamin",
    "    1000 μg/day × 7 days → weekly × 4 wks → monthly (lifelong)",
    "  Continue through pregnancy and postpartum",
  ].join("\n"), C.purple, C.white);

  // Critical warning banner
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:3.05, w:9.6, h:0.88, fill:{ color: "FFF0D0" }, line:{ color: C.gold, pt:2 } });
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:3.05, w:0.12, h:0.88, fill:{ color: C.gold }, line:{ color: C.gold } });
  s.addText([
    { text: "⚠  CRITICAL WARNING:  ", options:{fontSize:12, bold:true, color:C.crimson} },
    { text: "NEVER give folate alone in megaloblastic anemia without first checking B12 levels.", options:{fontSize:11, bold:true, color:C.darkGray} },
    { text: "\n  Folate alone corrects the blood picture but allows B12-related neurological damage (Subacute Combined Degeneration) to progress — sometimes irreversibly.", options:{fontSize:9.5, color:C.darkGray} }
  ], { x:0.45, y:3.05, w:9.3, h:0.88, valign:"middle" });

  // Lab sequence
  s.addText("Sequence of B12 Deficiency Development:", { x:0.2, y:4.0, w:9.6, h:0.28, fontSize:9.5, bold:true, color:C.navy });
  const seq = ["↓ Serum B12", "↑ MMA + Homocysteine", "↑ MCV (macro-ovalocytes)", "Hyperseg. neutrophils", "Megaloblastic anaemia", "Neurological damage (late)"];
  seq.forEach((tx,i) => {
    const x = 0.2 + i*1.63;
    s.addShape(pres.shapes.RECTANGLE, { x, y:4.32, w:1.5, h:0.65, fill:{ color: i<3?C.teal:C.crimson }, line:{ color: i<3?C.teal:C.crimson } });
    s.addText(tx, { x, y:4.32, w:1.5, h:0.65, fontSize:7.5, color:C.white, align:"center", valign:"middle", margin:2 });
    if(i<5) s.addText("→", { x:x+1.52, y:4.45, w:0.1, h:0.4, fontSize:11, bold:true, color:C.midGray, valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 16 — HEMOLYTIC ANEMIAS
// ════════════════════════════════════════════════════════════
makeDivider("HEMOLYTIC ANEMIAS", "AIHA · HELLP Syndrome · G6PD Deficiency · Hereditary Spherocytosis");

{
  let s = makeSlide("7. Hemolytic Anemias — Overview", "HEMOLYTIC");
  addBox(s, 0.2, 0.85, 4.7, 2.15, "Autoimmune Hemolytic Anemia (AIHA)", [
    "Warm AIHA (80–90%): IgG → anti-Rh antigens → splenic destruction",
    "Cold AIHA (10–20%): IgM → complement → intravascular hemolysis",
    "Associations: SLE, lymphoma, viral infections, drugs (methyldopa, penicillin)",
    "",
    "Labs: ↓Hb, spherocytes + polychromasia on smear",
    "↑ Reticulocyte, ↑ LDH, ↓ Haptoglobin, ↑ Indirect bilirubin",
    "DIRECT COOMBS TEST (DAT): POSITIVE — KEY diagnostic test",
    "",
    "Treatment: Prednisolone 1–2 mg/kg/day → IVIG if fails",
    "Splenectomy (2nd trimester if refractory)",
  ].join("\n"), C.orange, C.white);

  addBox(s, 5.1, 0.85, 4.7, 2.15, "HELLP Syndrome (Microangiopathic)", [
    "H = Hemolysis  |  EL = Elevated Liver enzymes  |  LP = Low Platelets",
    "Part of severe pre-eclampsia spectrum",
    "",
    "Mechanism: Endothelial dysfunction → platelet consumption +",
    "fibrin strands → RBC shearing → SCHISTOCYTES (helmet cells)",
    "",
    "Labs: ↓Hb + schistocytes, ↓Platelets (<100K), ↑LDH, ↑AST/ALT",
    "",
    "Definitive treatment: DELIVERY",
    "Supportive: Corticosteroids (fetal lung/platelet boost) + MgSO4",
  ].join("\n"), C.crimson, C.white);

  addBox(s, 0.2, 3.12, 4.7, 2.0, "G6PD Deficiency (India Relevant)", [
    "X-linked recessive; affects >400 million worldwide",
    "Common in: Tribals, Mediterranean, Sephardic Jews, Blacks",
    "",
    "Mechanism: ↓NADPH → oxidant injury → acute hemolysis",
    "Triggers: Primaquine, sulfonamides, nitrofurantoin, fava beans,",
    "  naphthalene (MOTHBALLS — very common in India!), infection",
    "",
    "Testing: G6PD quantitative assay — do AFTER hemolytic episode resolves",
    "  (reticulocytes have normal G6PD → falsely normal result during crisis)",
    "Neonatal hyperbilirubinemia in affected male infants",
  ].join("\n"), C.purple, C.white);

  addBox(s, 5.1, 3.12, 4.7, 2.0, "Hereditary Spherocytosis", [
    "Autosomal dominant; defect in RBC membrane (spectrin, ankyrin)",
    "Smear: Spherocytes (no central pallor) + polychromasia",
    "",
    "Diagnosis: EMA binding test (flow cytometry)",
    "  Sensitivity 86–94%, Specificity 94–97%",
    "  (Osmotic fragility test: older, sensitivity only 62%)",
    "",
    "In pregnancy: hemolytic crises possible; folic acid 5 mg/day",
    "Splenectomy before pregnancy if severe",
    "If crisis in pregnancy: transfusion; splenectomy 2nd trimester",
    "Fetal outcome: generally good",
  ].join("\n"), C.green, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 17 — APLASTIC ANEMIA
// ════════════════════════════════════════════════════════════
makeDivider("APLASTIC ANEMIA IN PREGNANCY", "Pancytopenia · Bone Marrow Failure · High Maternal-Fetal Morbidity");

{
  let s = makeSlide("8. Aplastic Anemia — Features & Management", "APLASTIC");
  addBox(s, 0.2, 0.85, 4.7, 2.0, "Pathophysiology & Features", [
    "Autoimmune T-cell mediated destruction of hematopoietic stem cells",
    "Triggers: Hepatitis, PNH, drugs (chloramphenicol, benzene, gold, CBZ)",
    "Result: Pancytopenia — ↓RBCs, ↓WBCs, ↓Platelets",
    "",
    "Symptoms:",
    "  Anemia: fatigue, pallor",
    "  Neutropenia: recurrent infections, fever, sepsis",
    "  Thrombocytopenia: petechiae, mucosal bleeding, PPH risk",
    "No splenomegaly (unlike hemolytic anemias)",
    "MOST SERIOUS complications: hemorrhage + sepsis",
  ].join("\n"), C.purple, C.white);

  addBox(s, 5.1, 0.85, 4.7, 2.0, "Investigations", [
    "CBC: Pancytopenia — ↓Hb, ↓WBC (<1500), ↓Platelets (<50K)",
    "Reticulocyte count: ↓↓ (marrow cannot respond)",
    "Peripheral smear: Normocytic normochromic; few cells; no dysplasia",
    "",
    "BONE MARROW BIOPSY: Hypocellular / empty marrow",
    "  with fatty replacement — KEY diagnostic finding",
    "",
    "Flow cytometry: Rule out PNH (CD55/CD59 deficiency)",
    "",
    "Severity (Camitta Criteria):",
    "  Severe: BM <25% + 2 of: Neutrophils <500, Plt <20K, Retic <1%",
    "  Very severe: Same + Neutrophils <200/μL",
  ].join("\n"), C.teal, C.white);

  addBox(s, 0.2, 2.97, 9.6, 2.18, "Management in Pregnancy", [
    "SUPPORTIVE (primary in pregnancy):",
    "  • RBC transfusions — maintain Hb >8 g/dL throughout",
    "  • Platelet transfusions — target >50,000 for delivery; >10,000 to prevent spontaneous bleeding",
    "  • G-CSF (filgrastim): boost neutrophil count; limited data in pregnancy",
    "  • Broad-spectrum antibiotics for infections",
    "",
    "IMMUNOSUPPRESSION:",
    "  • Anti-thymocyte globulin (ATG) + Cyclosporine: standard treatment; can be used in pregnancy",
    "  • Eltrombopag (TPO receptor agonist): limited pregnancy data; for refractory cases",
    "",
    "CONTRAINDICATED in pregnancy: Androgens (danazol, oxymetholone — TERATOGENIC) | Alkylating agents | BMT (defer to postpartum)",
    "",
    "2025 Meta-analysis (Arora et al., Eur J Haematol, PMID:39491801): Maternal mortality ~12% | Fetal loss ~15% | Most deaths from infection and hemorrhage",
  ].join("\n"), C.crimson, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 18 — THALASSEMIA DIVIDER
// ════════════════════════════════════════════════════════════
makeDivider("THALASSEMIAS", "~45 Million Carriers in India · Most Common Single-Gene Disorder Worldwide");

// ════════════════════════════════════════════════════════════
// SLIDE 19 — THALASSEMIA
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("9. Thalassemias — Types & Pathophysiology", "THALASSEMIA");
  s.addText("Types of Thalassemia (India Burden)", { x:0.2, y:0.85, w:9.6, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Type", "Genetics", "India Prevalence", "Clinical Severity"],
    ["β-Thal Trait (heterozygous)", "One β-globin mutation", "~3–4% of Indians", "Mild microcytic anemia; asymptomatic"],
    ["β-Thal Major (homozygous)", "Both β-globin mutated", "~10–15K births/year", "Transfusion-dependent from infancy"],
    ["β-Thal Intermedia", "Compound heterozygous", "Uncommon", "Moderate; variable transfusion"],
    ["α-Thal Trait (1–2 gene del)", "αα/-- or α-/αα", "High in NE India, tribals", "Silent/mild microcytic anemia"],
    ["HbH disease (3 gene del)", "--/-α", "Less common", "Moderate hemolytic anemia"],
    ["Hb Barts (4 gene del)", "--/--", "Rare", "Hydrops fetalis — fetal death in utero"],
    ["HbE + β-Thal", "HbE + β mutation", "VERY COMMON in NE India (Assam, Bengal)", "Clinically severe — similar to thal major"],
  ], { x:0.2, y:1.18, w:9.6, h:3.2, colW:[2.5,2.0,2.5,2.6], fontSize:8.2, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });

  addBox(s, 0.2, 4.45, 9.6, 0.72, "β-Thalassemia Pathophysiology",
    "Absent/reduced β-globin chains → excess unpaired α-chains → precipitate in erythroid precursors → Ineffective erythropoiesis + hemolysis → Bone marrow hyperplasia → Thalassemic facies (frontal bossing, maxillary prominence) → Extramedullary hematopoiesis → Splenomegaly, hepatomegaly",
    C.green, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 20 — THALASSEMIA INVESTIGATIONS + FLOWCHART IMAGE
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("9. Thalassemia — Screening Flowchart & Lab Findings", "THALASSEMIA");
  // Thalassemia screening flowchart image
  s.addImage({ data: thalFlowImg, x:0.2, y:0.82, w:4.5, h:4.38 });
  s.addText("Figure: Maternal screening algorithm for α- & β-thalassemia\n(Creasy & Resnik MFM 7e, Fig. 55.3)", { x:0.2, y:5.2, w:4.5, h:0.4, fontSize:7.5, color:C.midGray, italic:true, align:"center" });

  // Lab table
  s.addText("β-Thalassemia Trait vs. IDA — Key Lab Differences", { x:4.85, y:0.82, w:5.0, h:0.3, fontSize:9.5, bold:true, color:C.navy });
  s.addTable([
    ["Test", "β-Thal Trait", "IDA"],
    ["Hb", "9–11 g/dL", "↓"],
    ["MCV", "↓↓ (<75 fL) — disproportionate", "↓"],
    ["Hb A2 (HPLC)", "> 3.5% — KEY", "Normal"],
    ["Hb F", "Variable ↑", "Normal"],
    ["Ferritin", "Normal / ↑", "↓ (<15)"],
    ["TIBC", "Normal", "↑ (>400)"],
    ["RDW", "NORMAL", "↑ (>15%)"],
    ["Mentzer Index (MCV/RBC)", "< 13", "> 13"],
  ], { x:4.85, y:1.15, w:5.0, h:2.62, colW:[2.5,1.4,1.1], fontSize:8.8, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });

  addBox(s, 4.85, 3.85, 5.0, 1.38, "Management of β-Thal Trait in Pregnancy", [
    "• Do NOT give excess iron (ferritin normal — risk of overload)",
    "• Folic acid 5 mg/day (compensate for chronic hemolysis)",
    "• Genetic counseling — partner testing (HPLC) MANDATORY",
    "• If both parents carriers: prenatal diagnosis",
    "  – CVS at 10–12 weeks (preferred) or amniocentesis 15–18 wks",
    "• Serial USS for fetal growth (q4 weekly from 24 wks)",
    "• β-Thal major/intermedia: regular transfusions; deferoxamine",
    "  (oral chelators deferasirox/deferiprone TERATOGENIC — stop pre-conception)",
  ].join("\n"), C.green, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 21 — SICKLE CELL DIVIDER
// ════════════════════════════════════════════════════════════
makeDivider("SICKLE CELL HEMOGLOBINOPATHY", "~15 Million Carriers in India · National Elimination Mission 2023 (Target: 2047)");

// ════════════════════════════════════════════════════════════
// SLIDE 22 — SICKLE CELL FEATURES
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("10. Sickle Cell Disease — Pathophysiology & Manifestations", "SICKLE CELL");
  addBox(s, 0.2, 0.85, 4.7, 1.85, "Pathophysiology", [
    "Point mutation: Glutamic acid → Valine at β-globin position 6",
    "HbS produced → deoxygenation/dehydration → polymerization → SICKLING",
    "",
    "Two main consequences:",
    "1. Vaso-occlusion: pain crises, organ infarction, stroke, AVN",
    "2. Hemolysis: chronic anemia (Hb 6–9 g/dL), jaundice, pigment stones",
    "",
    "Pregnancy worsens SCA: ↑ metabolic demand, hypercoagulability,",
    "  ↑ infection risk, ↓ renal concentration → more complications",
  ].join("\n"), C.crimson, C.white);

  addBox(s, 5.1, 0.85, 4.7, 1.85, "India Context", [
    "~15 million sickle cell trait carriers in India",
    "Predominantly tribal belt: MP, Chhattisgarh, Jharkhand, Odisha,",
    "  Maharashtra (Vidarbha), NE India",
    "",
    "Govt of India: National Sickle Cell Anaemia Elimination Mission",
    "  Launched: 2023  |  Target: Elimination by 2047",
    "",
    "HbSS (SCA): Hb 6–9 g/dL; Hb electrophoresis — HbS >80%, No HbA",
    "HbAS (Trait): Normal Hb; HbS 35–45%; HbA present",
    "HbSC: Moderate; may worsen in pregnancy",
  ].join("\n"), C.navy, C.white);

  // Clinical manifestations table
  s.addText("Pregnancy-Specific Manifestations (BOX 55.2 — Creasy & Resnik)", { x:0.2, y:2.8, w:9.6, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["System", "Manifestation in Pregnancy"],
    ["Hematologic", "Chronic hemolytic anemia (Hb 6–9), jaundice, reticulocytosis"],
    ["Pain", "Vaso-occlusive crises: 20–50% of pregnancies have ≥1 crisis"],
    ["Pulmonary", "ACUTE CHEST SYNDROME: up to 20% of SCA pregnancies — most severe complication"],
    ["Obstetric", "Pre-eclampsia ↑, Preterm birth + FGR up to 45%, Perinatal death ↑"],
    ["Renal", "Pyelonephritis ↑ — screen urine culture each trimester"],
    ["VTE", "Increased — especially with hospitalisation"],
  ], { x:0.2, y:3.12, w:9.6, h:2.15, colW:[2.0,7.6], fontSize:8.8, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 23 — SICKLE CELL MANAGEMENT
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("10. Sickle Cell Disease — Management in Pregnancy", "SICKLE CELL Rx");
  addBox(s, 0.2, 0.85, 4.7, 1.8, "Antenatal Management", [
    "Folic acid 5 mg/day (chronic hemolysis — high cell turnover)",
    "Penicillin prophylaxis 500 mg BD (functional asplenia)",
    "Low-dose aspirin 75–150 mg/day from 12 wks (↓ pre-eclampsia)",
    "LMWH thromboprophylaxis when hospitalised or immobile",
    "Vaccines: pneumococcal, meningococcal, Hib, influenza",
    "STOP HYDROXYUREA: teratogenic risk (stop 3 months pre-conception)",
    "Do NOT give iron routinely (may be iron-overloaded)",
    "Serial USS q4-weekly from 24 wks (FGR risk up to 45%)",
    "Prenatal diagnosis: CVS / amniocentesis",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.1, 0.85, 4.7, 1.8, "Management of Painful Crisis", [
    "HYDRATION: IV fluids 2–3 L/day (avoid overhydration → pulmonary oedema)",
    "OXYGEN: maintain SpO2 >95%",
    "ANALGESIA: IV morphine + paracetamol",
    "  (Avoid NSAIDs in 3rd trimester)",
    "Warm packs to painful areas",
    "ANTIBIOTICS if infection suspected (common precipitant)",
    "",
    "TRANSFUSION if:",
    "  Hb <6 g/dL  or  Hct <18%",
    "  Prophylactic transfusions → reduce crises 50% → 14% (RCT, n=72)",
  ].join("\n"), C.orange, C.white);

  addBox(s, 0.2, 2.77, 9.6, 1.38, "Acute Chest Syndrome (ACS) — Up to 20% of SCA Pregnancies", [
    "Most severe complication | Definition: Fever + Chest pain + New pulmonary infiltrate + ↓SpO2",
    "",
    "Treatment: Hydration + O2 + Incentive spirometry + Antibiotics (cephalosporin + macrolide) + Bronchodilators",
    "PARTIAL EXCHANGE TRANSFUSION: Goal HbA >50% and Hct >25% — CORNERSTONE of treatment",
    "Consider ICU admission",
  ].join("\n"), C.crimson, C.white);

  addBox(s, 0.2, 4.22, 4.7, 0.98, "Intrapartum", [
    "SpO2 >95% | IV fluids | Epidural analgesia (reduces stress)",
    "Continuous FHR monitoring | Cross-matched blood available",
    "Active management of 3rd stage",
  ].join("\n"), C.navy, C.white);

  addBox(s, 5.1, 4.22, 4.7, 0.98, "Postpartum", [
    "Continue LMWH thromboprophylaxis (high VTE risk)",
    "Restart hydroxyurea postpartum if NOT breastfeeding",
    "Hydroxyurea CONTRAINDICATED while breastfeeding",
  ].join("\n"), C.green, C.white);
}

// ════════════════════════════════════════════════════════════
// SLIDE 24 — ANEMIA OF CHRONIC DISEASE
// ════════════════════════════════════════════════════════════
makeDivider("ANEMIA OF CHRONIC DISEASE", "ACD / Anemia of Inflammation — Hepcidin-Mediated Iron Sequestration");

{
  let s = makeSlide("11. Anemia of Chronic Disease — Pathophysiology & Management", "ACD");
  addBox(s, 0.2, 0.85, 5.5, 2.55, "Hepcidin Mechanism (India: TB, Malaria, HIV)", [
    "Chronic infection/inflammation → IL-6, TNF-α, IL-1β",
    "  ↓",
    "Liver produces ↑ HEPCIDIN (acute phase reactant)",
    "  ↓",
    "Hepcidin inactivates FERROPORTIN (only known iron exporter)",
    "  ↓",
    "Iron trapped in macrophages and enterocytes",
    "  ↓",
    "↓ Serum iron → ↓ Erythropoiesis → ACD",
    "  ALSO: shortened RBC lifespan + blunted EPO response",
    "",
    "In India: TB and malaria are MAJOR causes of ACD in pregnancy",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.85, 0.85, 3.9, 2.55, "Key Clinical Features", [
    "Usually mild to moderate anemia",
    "Normocytic normochromic (usual)",
    "Symptoms of underlying disease",
    "  predominate (fever, weight loss)",
    "No pica, koilonychia, or typical IDA",
    "Splenomegaly (if malaria/chronic cause)",
    "",
    "TIBC is LOW (key difference from IDA)",
    "Ferritin is HIGH (iron sequestered,",
    "  not actually deficient)",
  ].join("\n"), C.orange, C.white);

  s.addText("IDA vs. ACD vs. Combined Deficiency", { x:0.2, y:3.48, w:9.6, h:0.3, fontSize:10, bold:true, color:C.navy });
  s.addTable([
    ["Test", "IDA", "ACD Only", "IDA + Inflammation", "Sideroblastic"],
    ["Serum iron", "↓↓", "↓", "↓", "↑"],
    ["TIBC", "↑ (>400)", "↓", "↓/Normal", "Normal"],
    ["% Saturation", "↓ (<16%)", "↓ (<30%)", "↓ (<20%)", "↑ (>45%)"],
    ["Ferritin", "↓ (<15)", "↑ (>200)", "↓ (<30–100)", "↑ (>200)"],
    ["Hepcidin", "↓", "↑", "Variable", "Normal"],
    ["sTfR", "↑↑", "Normal", "↑", "Normal"],
  ], { x:0.2, y:3.8, w:9.6, h:1.6, colW:[2.0,1.6,1.6,2.2,2.2], fontSize:8.5, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"center", valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 25 — MANAGEMENT FLOWCHART
// ════════════════════════════════════════════════════════════
makeDivider("MANAGEMENT ALGORITHM", "Diagnostic Flowchart · Severity-Based Treatment · Follow-Up");

{
  let s = makeSlide("12. Diagnostic & Management Flowchart — Anemia in Pregnancy", "MANAGEMENT");
  // Top: Anemia box
  s.addShape(pres.shapes.RECTANGLE, { x:3.5, y:0.82, w:3.0, h:0.55, fill:{ color: C.crimson }, line:{ color: C.crimson } });
  s.addText("ANEMIA IN PREGNANCY\nHb below trimester threshold", { x:3.5, y:0.82, w:3.0, h:0.55, fontSize:8.5, bold:true, color:C.white, align:"center", valign:"middle", margin:2 });

  // Step 1
  s.addShape(pres.shapes.RECTANGLE, { x:3.5, y:1.48, w:3.0, h:0.5, fill:{ color: C.navy }, line:{ color: C.navy } });
  s.addText("STEP 1: CBC + Reticulocyte + Peripheral Smear", { x:3.5, y:1.48, w:3.0, h:0.5, fontSize:7.5, bold:true, color:C.white, align:"center", valign:"middle", margin:2 });

  // 3 branches
  const branches = [
    {x:0.2, label:"MICROCYTIC\nMCV <80", sub:"Iron Studies\nFerritin (key!)\nTIBC\nMentzer Index", sub2:"↓ Ferritin → IDA\nNormal Ferritin\n+ Low MCV → Thalassemia\n(HPLC / Hb electrophoresis)", color:C.teal},
    {x:3.65, label:"NORMOCYTIC\nMCV 80–100", sub:"Reticulocyte count", sub2:"Low Retic → ACD /\nAplasia / Renal / ACD\n\nHigh Retic → HEMOLYSIS\n(Coombs, LDH,\nHaptoglobin, HPLC)", color:C.orange},
    {x:7.1, label:"MACROCYTIC\nMCV >100", sub:"Serum B12\nSerum/RBC Folate\nMMA, Homocysteine", sub2:"↓ Folate → Folic acid 5mg\n↓ B12 → IM cyanocobalamin\nCheck B12 FIRST!", color:C.purple},
  ];
  branches.forEach(b => {
    s.addShape(pres.shapes.RECTANGLE, { x:b.x, y:2.1, w:2.65, h:0.55, fill:{ color: b.color }, line:{ color: b.color } });
    s.addText(b.label, { x:b.x, y:2.1, w:2.65, h:0.55, fontSize:8, bold:true, color:C.white, align:"center", valign:"middle", margin:1 });
    s.addShape(pres.shapes.RECTANGLE, { x:b.x, y:2.72, w:2.65, h:0.58, fill:{ color: C.white }, line:{ color: b.color, pt:1 } });
    s.addText(b.sub, { x:b.x+0.05, y:2.72, w:2.55, h:0.58, fontSize:7.5, color:C.darkGray, valign:"middle", margin:2 });
    s.addShape(pres.shapes.RECTANGLE, { x:b.x, y:3.37, w:2.65, h:0.92, fill:{ color: "F7F7FF" }, line:{ color: b.color, pt:1 } });
    s.addText(b.sub2, { x:b.x+0.05, y:3.37, w:2.55, h:0.92, fontSize:7.5, color:C.darkGray, valign:"top", margin:2 });
  });

  // Bottom: Severity-based management banner
  s.addShape(pres.shapes.RECTANGLE, { x:0.2, y:4.35, w:9.6, h:0.88, fill:{ color: C.navy }, line:{ color: C.navy } });
  const sev = [
    {label:"MILD\n(Hb 9–11)", rx:"Oral iron\n200mg elem Fe/day", c:C.green},
    {label:"MODERATE\n(Hb 7–9)", rx:"Oral → IV Iron\n(escalate if poor response)", c:C.gold},
    {label:"SEVERE\n(Hb <7)", rx:"IV Iron + Consider\nBlood Transfusion", c:C.orange},
    {label:"VERY SEVERE\n(Hb <5–6)", rx:"Transfusion +\nICU Assessment", c:C.crimson},
  ];
  sev.forEach((sv,i) => {
    s.addShape(pres.shapes.RECTANGLE, { x:0.25 + i*2.42, y:4.37, w:2.32, h:0.83, fill:{ color: sv.c }, line:{ color: sv.c } });
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  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 26 — FOLLOW-UP & MONITORING
// ════════════════════════════════════════════════════════════
{
  let s = makeSlide("Follow-Up Schedule & Treatment Monitoring", "FOLLOW-UP");
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  s.addTable([
    ["Time Point", "What to Check"],
    ["Booking (1st ANC)", "Hb, MCV, Ferritin, Blood group, Hb electrophoresis if indicated"],
    ["20 weeks", "Hb repeat if initially anaemic; review IFA compliance"],
    ["28 weeks", "Hb, Ferritin; escalate to IV iron if oral insufficient"],
    ["36 weeks", "Hb, Blood group, Crossmatch — prepare for delivery"],
    ["4 weeks after starting iron", "Reticulocyte ↑ → Hb rise expected 1–2 g/dL/month"],
    ["6 weeks postpartum", "Hb; continue iron until ferritin >50 ng/mL"],
    ["3 months postpartum", "Ferritin — confirm stores replete before stopping iron"],
  ], { x:0.2, y:1.17, w:5.5, h:3.35, colW:[2.2,3.3], fontSize:8.8, border:{ type:"solid", color:"D0D0D0", pt:0.5 }, fontFace:"Calibri", align:"left", valign:"middle" });

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    "Reticulocyte ↑ within 1 WEEK of iron therapy",
    "Hb starts rising by WEEK 2",
    "Expected: 1–2 g/dL rise per month",
    "Target ferritin: 50–100 ng/mL (stores replete)",
    "",
    "If NO response by 4 weeks:",
    "  • Check compliance",
    "  • Check absorption (celiac, H. pylori)",
    "  • Check for ongoing blood loss",
    "  • Reconsider diagnosis (thalassemia? ACD?)",
    "  • Switch to IV iron",
  ].join("\n"), C.teal, C.white);

  addBox(s, 5.85, 3.12, 3.9, 1.4, "Postpartum Continuation", [
    "Continue iron 3 months postpartum",
    "Delayed cord clamping (30–60 seconds) — ↑ neonatal iron stores",
    "Check neonatal ferritin — if <25th percentile → long-term neuro risk",
    "Genetic counselling referral for hemoglobinopathies",
    "Pre-conception optimization before next pregnancy",
  ].join("\n"), C.green, C.white);

  // Bottom mnemonics
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  s.addText([
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    { text: "PHILIP (IDA causes): Poor diet · High demand · Increased losses · Low absorption · Infection · Pre-existing deficiency   |   ", options:{fontSize:8.5, color:C.darkGray} },
    { text: "FARM (IDA vs ACD): Ferritin LOW/HIGH · serum iron (Acidity = ↓both) · TIBC Raised/low · Macrophages trap iron in ACD", options:{fontSize:8.5, color:C.darkGray} }
  ], { x:0.3, y:4.58, w:9.4, h:0.65, valign:"middle" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 27 — KEY TAKEAWAYS + CLOSING
// ════════════════════════════════════════════════════════════
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    ["01", "DEFINE correctly: Hb <11 (1st/3rd T), <10.5 (2nd T). High Hb >14.5 is also dangerous — paradox!", C.crimson],
    ["02", "52.2% of Indian pregnant women are anemic (NFHS-5). Iron deficiency = most common cause (>50%)", C.teal],
    ["03", "FERRITIN is the single best test. IDA: TIBC ↑, Ferritin ↓. ACD: TIBC ↓, Ferritin ↑. Thal: Hb A2 ↑", C.gold],
    ["04", "IDA Treatment: Oral iron (empty stomach + Vit C). 3rd trimester → IV iron preferred. Hb <6 → transfuse", C.orange],
    ["05", "NEVER give folate alone without checking B12 — risk of masking subacute combined degeneration", C.purple],
    ["06", "Sickle cell crises: hydrate + O2 + analgesia. Acute chest syndrome = exchange transfusion (goal HbA >50%)", C.green],
    ["07", "Thalassemia trait: NO excess iron. HPLC mandatory + genetic counselling + partner testing", C.teal],
    ["08", "Aplastic anemia: ATG + cyclosporine. No androgens (teratogenic). Maternal mortality ~12% (meta-analysis 2025)", C.crimson],
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// ─── WRITE FILE ─────────────────────────────────────────────
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// Anemia in Pregnancy — OBGYN Seminar PowerPoint Builder
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pres.layout  = "LAYOUT_WIDE";   // 13.3" × 7.5"
pres.title   = "Anemia in Pregnancy";
pres.author  = "OBGYN Seminar";
pres.subject = "Comprehensive Seminar Notes — India Focus";

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    fontSize:44, bold:true, color:C.white, fontFace:"Calibri",
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x:1.2, y:3.65, w:W-2, h:0.7,
      fontSize:20, color:C.silver, fontFace:"Calibri", italic:true,
    });
  }
}

function infoBox(slide, x, y, w, h, title, bodyLines, titleBg, bodyBg) {
  titleBg = titleBg || C.teal;
  bodyBg  = bodyBg  || C.lightTeal;
  slide.addShape(pres.ShapeType.rect, { x, y, w, h:0.42, fill:{color:titleBg}, line:{color:titleBg}, rectRadius:0.05 });
  slide.addText(title, { x, y, w, h:0.42, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const bh = h - 0.42;
  slide.addShape(pres.ShapeType.rect, { x, y:y+0.42, w, h:bh, fill:{color:bodyBg}, line:{color:"C8DCE4"} });
  const items = bodyLines.map((t,i) => ({
    text: t,
    options: { bullet:{code:"2022"}, fontSize:10.5, color:C.darkGray, breakLine: i < bodyLines.length-1 }
  }));
  slide.addText(items, { x:x+0.08, y:y+0.44, w:w-0.16, h:bh-0.1, fontFace:"Calibri", valign:"top" });
}

function tableSlide(slide, headers, rows, x, y, w, colWidths) {
  const tblData = [];
  tblData.push(headers.map(h => ({
    text: h,
    options: { bold:true, color:C.white, fill:C.navy, fontSize:11, align:"center" }
  })));
  rows.forEach((row, ri) => {
    tblData.push(row.map(cell => ({
      text: cell,
      options: { fontSize:10, color:C.darkGray, fill: ri%2===0 ? C.offWhite : C.white, align:"center" }
    })));
  });
  slide.addTable(tblData, {
    x, y, w, colW: colWidths,
    border:{ type:"solid", pt:0.5, color:"C8D6E5" },
    fontFace:"Calibri",
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.navy);
  // Crimson diagonal band
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:4.2, h:H, fill:{color:C.crimson}, line:{color:C.crimson} });
  s.addShape(pres.ShapeType.rect, { x:4.2, y:0, w:0.35, h:H, fill:{color:C.gold}, line:{color:C.gold} });

  // Left panel text
  s.addText("OBGYN\nSEMINAR", {
    x:0.3, y:0.5, w:3.6, h:1.4,
    fontSize:18, bold:true, color:C.white, fontFace:"Calibri", charSpacing:4, align:"center",
  });
  s.addShape(pres.ShapeType.rect, { x:0.5, y:1.95, w:3.1, h:0.06, fill:{color:C.white}, line:{color:C.white} });
  s.addText("India Focus\nNFHS-5 Data & WHO 2024 Guidelines", {
    x:0.3, y:2.1, w:3.6, h:1.0,
    fontSize:11, color:C.silver, fontFace:"Calibri", align:"center", italic:true,
  });

  // Right panel — main title
  s.addText("ANEMIA IN\nPREGNANCY", {
    x:4.8, y:1.2, w:8.1, h:2.8,
    fontSize:60, bold:true, color:C.white, fontFace:"Calibri",
  });
  s.addShape(pres.ShapeType.rect, { x:4.8, y:4.1, w:8.1, h:0.06, fill:{color:C.gold}, line:{color:C.gold} });
  s.addText("Comprehensive Seminar for Postgraduate OBGYN Residents", {
    x:4.8, y:4.25, w:8.1, h:0.6,
    fontSize:18, color:C.silver, fontFace:"Calibri", italic:true,
  });
  s.addText([
    { text: "Sources: ", options:{ bold:true, color:C.gold } },
    { text: "Creasy & Resnik's MFM 7e  ·  Goldman-Cecil Medicine  ·  Harrison's 22e  ·  NFHS-5 (2019-21)  ·  WHO 2024", options:{ color:C.silver } }
  ], { x:4.8, y:5.1, w:8.1, h:0.5, fontSize:10, fontFace:"Calibri" });

  // Bottom bar
  s.addShape(pres.ShapeType.rect, { x:0, y:H-0.45, w:W, h:0.45, fill:{color:"06102A"}, line:{color:"06102A"} });
  s.addText("RR = 3.5 for maternal death with Hb < 5 g/dL  ·  52.2% of pregnant women in India are anemic (NFHS-5)", {
    x:0.3, y:H-0.45, w:W-0.6, h:0.45,
    fontSize:10, color:C.silver, fontFace:"Calibri", align:"center", valign:"middle", italic:true,
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — TABLE OF CONTENTS
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Seminar Overview", C.navy, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  const sections = [
    ["01", "WHO Definition & Severity Classification"],
    ["02", "Epidemiological Burden in India (NFHS-5)"],
    ["03", "Classification of Causes"],
    ["04", "Effects on Mother & Fetus"],
    ["05", "Individual Causes — 10 Entities"],
    ["06", "Diagnostic Algorithm (Flowchart)"],
    ["07", "Management Flowchart & Mnemonics"],
  ];

  const col1 = sections.slice(0,4);
  const col2 = sections.slice(4);

  function tocCol(items, xStart) {
    items.forEach((item, i) => {
      const yy = 1.25 + i * 1.2;
      s.addShape(pres.ShapeType.rect, { x:xStart, y:yy, w:0.65, h:0.65, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.06 });
      s.addText(item[0], { x:xStart, y:yy, w:0.65, h:0.65, fontSize:18, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
      s.addText(item[1], { x:xStart+0.75, y:yy+0.05, w:5.4, h:0.55, fontSize:15, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
    });
  }
  tocCol(col1, 0.5);
  tocCol(col2, 7.0);
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — SECTION DIVIDER: Definition
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "01", "WHO Definition", "Trimester-based Hb thresholds & Severity Classification");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — WHO DEFINITION & SEVERITY
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "WHO Definition — Anemia in Pregnancy", C.navy, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // Definition box
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:12.7, h:0.75, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.08 });
  s.addText("Hemoglobin concentration below which clinical intervention is warranted, given age, sex, and physiological state (WHO)", {
    x:0.35, y:1.1, w:12.6, h:0.75, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", align:"center", margin:0,
  });

  // Trimester threshold table
  tableSlide(s,
    ["Trimester / State", "Hb Threshold (g/dL)", "Hematocrit (%)"],
    [
      ["1st Trimester", "< 11.0", "< 33%"],
      ["2nd Trimester", "< 10.5", "< 32%"],
      ["3rd Trimester", "< 11.0", "< 33%"],
      ["Postpartum", "< 10.0", "< 30%"],
    ],
    0.3, 2.0, 5.8, [2.4, 1.7, 1.7]
  );

  // Severity classification table
  tableSlide(s,
    ["Category", "Hb (g/dL)", "Clinical Significance"],
    [
      ["No Anemia", "≥ 11.0", "Normal"],
      ["Mild", "10.0 – 10.9", "Compensated; fatigue"],
      ["Moderate", "7.0 – 9.9", "High-output state; fetal risk begins"],
      ["Severe", "< 7.0", "Significant maternal-fetal morbidity"],
      ["Very Severe / Life-threatening", "< 5.0", "CCF, ICU, maternal mortality risk"],
    ],
    6.4, 2.0, 6.6, [2.6, 1.4, 2.6]
  );

  s.addText("Normal adult non-pregnant Hb: 14.0 ± 2.0 g/dL  |  Lower limit non-pregnant: 12.0 g/dL", {
    x:0.3, y:6.55, w:12.7, h:0.4,
    fontSize:11, italic:true, color:C.teal, fontFace:"Calibri", align:"center",
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — SECTION DIVIDER: Epidemiology
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "02", "Epidemiological Burden in India", "NFHS-5 Data 2019-21 | Staggering National Statistics");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — INDIA EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Anemia in Pregnancy — India's Burden (NFHS-5, 2019-21)", C.navy, C.white);
  accentBar(s, C.gold);
  footerLine(s);

  // Big stat boxes
  const stats = [
    ["52.2%", "Pregnant women\nanemic in India"],
    ["1.4%", "Severe anemia\n(Hb < 7 g/dL)"],
    ["57%", "Women of\nreproductive age"],
    ["61.5%", "Adolescent\npregnant women"],
  ];
  stats.forEach((st, i) => {
    const xx = 0.3 + i * 3.22;
    s.addShape(pres.ShapeType.rect, { x:xx, y:1.15, w:3.0, h:1.7, fill:{color:C.navy}, line:{color:C.crimson}, rectRadius:0.1 });
    s.addText(st[0], { x:xx, y:1.15, w:3.0, h:0.95, fontSize:36, bold:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"bottom", margin:0 });
    s.addText(st[1], { x:xx+0.1, y:2.1, w:2.8, h:0.7, fontSize:12, color:C.silver, fontFace:"Calibri", align:"center", valign:"top" });
  });

  // State hotspots
  s.addShape(pres.ShapeType.rect, { x:0.3, y:3.05, w:6.2, h:0.38, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.05 });
  s.addText("STATE / DISTRICT HOTSPOTS", { x:0.3, y:3.05, w:6.2, h:0.38, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const hotspots = [
    ["Bihar (State)", "63.1%"],
    ["Ladakh (UT)", "71.4%"],
    ["Udalgiri, Assam (District)", "81.5%"],
    ["Scheduled Tribes", "59.3%"],
  ];
  hotspots.forEach((h, i) => {
    const yy = 3.5 + i * 0.62;
    s.addShape(pres.ShapeType.rect, { x:0.3, y:yy, w:4.2, h:0.52, fill:{color: i%2===0 ? C.white : C.lightTeal}, line:{color:"C8DCE4"} });
    s.addShape(pres.ShapeType.rect, { x:4.5, y:yy, w:2.0, h:0.52, fill:{color:C.crimson}, line:{color:C.crimson} });
    s.addText(h[0], { x:0.4, y:yy, w:4.0, h:0.52, fontSize:12, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
    s.addText(h[1], { x:4.5, y:yy, w:2.0, h:0.52, fontSize:15, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  });

  // Risk factors
  s.addShape(pres.ShapeType.rect, { x:6.9, y:3.05, w:6.1, h:0.38, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.05 });
  s.addText("RISK FACTORS (Adjusted Odds Ratios)", { x:6.9, y:3.05, w:6.1, h:0.38, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const risks = [
    ["No formal education", "aOR = 1.41"],
    ["Poorest wealth quintile", "aOR = 1.69"],
    ["Tobacco / alcohol use", "aOR = 1.39"],
    ["Short birth interval", "↑ Risk"],
    ["Eastern India tribal belt", "Highest prevalence"],
  ];
  risks.forEach((r, i) => {
    const yy = 3.5 + i * 0.62;
    s.addShape(pres.ShapeType.rect, { x:6.9, y:yy, w:4.2, h:0.52, fill:{color: i%2===0 ? C.white : C.lightTeal}, line:{color:"C8DCE4"} });
    s.addShape(pres.ShapeType.rect, { x:11.1, y:yy, w:1.7, h:0.52, fill:{color:C.teal}, line:{color:C.teal} });
    s.addText(r[0], { x:7.0, y:yy, w:4.0, h:0.52, fontSize:12, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
    s.addText(r[1], { x:11.1, y:yy, w:1.7, h:0.52, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — SECTION DIVIDER: Classification
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "03", "Classification of Causes", "Hereditary vs. Acquired — Complete Taxonomy");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — CAUSES CLASSIFICATION
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Classification of Anemia in Pregnancy", C.navy, C.white);
  accentBar(s, C.teal);
  footerLine(s);

  // HEREDITARY column
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:5.9, h:0.45, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.06 });
  s.addText("HEREDITARY (Genetic)", { x:0.3, y:1.1, w:5.9, h:0.45, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  const hereditary = [
    ["Hemoglobinopathies", "Sickle cell (SS/SC/S-βThal), HbC, HbE, HbD"],
    ["Thalassemias", "α-Thalassemia (gene deletions), β-Thalassemia (point mutations)"],
    ["RBC Enzyme Defects", "G6PD deficiency (X-linked recessive) — hemolytic crises"],
    ["RBC Membrane Disorders", "Hereditary spherocytosis (AD), Hereditary elliptocytosis"],
  ];
  hereditary.forEach((item, i) => {
    const yy = 1.65 + i * 1.0;
    s.addShape(pres.ShapeType.rect, { x:0.3, y:yy, w:1.95, h:0.82, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.05 });
    s.addText(item[0], { x:0.3, y:yy, w:1.95, h:0.82, fontSize:10.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0.05 });
    s.addShape(pres.ShapeType.rect, { x:2.3, y:yy, w:3.9, h:0.82, fill:{color:C.white}, line:{color:"BDD3E0"} });
    s.addText(item[1], { x:2.4, y:yy, w:3.7, h:0.82, fontSize:10.5, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
  });

  // ACQUIRED column
  s.addShape(pres.ShapeType.rect, { x:6.8, y:1.1, w:6.2, h:0.45, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.06 });
  s.addText("ACQUIRED (Most Common in India)", { x:6.8, y:1.1, w:6.2, h:0.45, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  const acquired = [
    ["IDA  #1", "Most common; >50% of all pregnancy anemia in India", C.crimson],
    ["Megaloblastic  #2", "Folate (most common), Vitamin B12 deficiency", C.crimson],
    ["Physiological", "Normal dilutional anemia — plasma ↑47%, RBC ↑17%", C.teal],
    ["Acute Blood Loss", "APH (placenta previa, abruption), PPH", C.teal],
    ["ACD", "Hepcidin mechanism; TB, malaria, HIV in India", C.teal],
    ["Hemolytic", "AIHA (Coombs+), HELLP, TTP/HUS, Drug-induced", C.navy],
    ["Aplastic Anemia", "Bone marrow failure; pancytopenia; Camitta criteria", C.navy],
  ];
  acquired.forEach((item, i) => {
    const yy = 1.65 + i * 0.73;
    s.addShape(pres.ShapeType.rect, { x:6.8, y:yy, w:1.6, h:0.63, fill:{color:item[2]}, line:{color:item[2]}, rectRadius:0.04 });
    s.addText(item[0], { x:6.8, y:yy, w:1.6, h:0.63, fontSize:10, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0.04 });
    s.addShape(pres.ShapeType.rect, { x:8.45, y:yy, w:4.55, h:0.63, fill:{color: i%2===0 ? C.white : C.lightTeal}, line:{color:"BDD3E0"} });
    s.addText(item[1], { x:8.55, y:yy, w:4.35, h:0.63, fontSize:10.5, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — SECTION DIVIDER: Effects
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "04", "Effects on Mother & Fetus", "Maternal Mortality · Fetal Outcomes · Paradox of High Hb");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — EFFECTS ON MOTHER & FETUS
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Effects on Mother & Fetus", C.navy, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // Maternal effects
  infoBox(s, 0.3, 1.15, 4.0, 2.9, "ANTENATAL MATERNAL EFFECTS", [
    "High-output cardiac failure (severe anemia)",
    "Increased infections: UTI, pneumonia, TB",
    "Preterm labor risk (meta-analysis confirmed)",
    "PROM — membrane weakness",
    "Increased placental weight (compensatory)",
    "Pre-eclampsia ↑ in sickle cell disease",
  ], C.teal, C.lightTeal);

  infoBox(s, 4.5, 1.15, 4.0, 2.9, "INTRAPARTUM & POSTPARTUM EFFECTS", [
    "Poor uterine contractions — iron impairs smooth muscle",
    "Prolonged labour, poor maternal stamina",
    "PPH — primary cause of maternal mortality in India",
    "Puerperal sepsis — reduced immunity",
    "Poor lactation; slow wound healing (LSCS)",
    "Postpartum depression (iron deficiency association)",
  ], C.crimson, "#FDECEA");

  infoBox(s, 8.9, 1.15, 4.1, 2.9, "FETAL & NEONATAL EFFECTS", [
    "Hb 9-11 → Generally good outcome",
    "Hb 7-9 → Preterm birth, low birth weight",
    "Hb < 7 → FGR/SGA, perinatal death",
    "Hb < 6 → Stillbirth, abnormal oxygenation",
    "Neonatal ferritin <25th %ile → neurodevelopmental delays",
    "Folate deficiency → Neural tube defects (periconceptional)",
  ], C.navy, C.lightGray);

  // Mortality stat
  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.2, w:8.0, h:1.0, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.08 });
  s.addText([
    { text: "RR = 3.5 ", options:{ fontSize:28, bold:true, color:C.gold } },
    { text: "for maternal death with Hb < 5 g/dL in Asia, Africa & Latin America\n", options:{ fontSize:14, color:C.white } },
    { text: "Anemia is one of the top 3 causes of maternal mortality in India — alongside hemorrhage and hypertensive disorders", options:{ fontSize:11, italic:true, color:"FFD0CC" } },
  ], { x:0.4, y:4.2, w:7.8, h:1.0, fontFace:"Calibri", valign:"middle" });

  // Paradox box
  s.addShape(pres.ShapeType.rect, { x:8.6, y:4.2, w:4.4, h:1.0, fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.08 });
  s.addText([
    { text: "⚠ HIGH Hb PARADOX\n", options:{ fontSize:13, bold:true, color:C.navy } },
    { text: "Maternal Hb > 14.5 g/dL early in pregnancy → stillbirth, SGA, LBW. High Hb = inadequate plasma volume expansion → poor placentation", options:{ fontSize:10, color:C.darkGray } },
  ], { x:8.7, y:4.2, w:4.2, h:1.0, fontFace:"Calibri", valign:"middle" });

  // Fetal table
  tableSlide(s,
    ["Hb Severity", "Fetal / Neonatal Impact"],
    [
      ["Mild (9-11)", "Generally good fetal outcome"],
      ["Moderate (7-9)", "↑ Preterm birth, ↑ low birth weight"],
      ["Severe (<7)", "FGR/SGA, perinatal death, non-reassuring FHR"],
      ["Very Severe (<6)", "Abnormal fetal oxygenation, stillbirth"],
    ],
    0.3, 5.35, 12.7, [2.5, 10.2]
  );
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — SECTION DIVIDER: Individual Causes
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "05", "Individual Causes of Anemia", "Pathophysiology · Clinical Features · Investigations · Treatment");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — PHYSIOLOGICAL ANEMIA
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5A. Physiological (Dilutional) Anemia of Pregnancy", C.teal, C.white);
  accentBar(s, C.teal);
  footerLine(s);

  // Changes table
  tableSlide(s,
    ["Parameter", "Change in Pregnancy"],
    [
      ["Total Blood Volume", "↑ 40-45% (max at 34 weeks)"],
      ["Plasma Volume", "↑ 47%"],
      ["RBC Mass", "↑ only 17-20% (reaches max at term)"],
      ["Net Result", "Relative hemodilution → ↓ Hb, Hct, RBC count"],
    ],
    0.3, 1.15, 6.0, [2.8, 3.2]
  );

  infoBox(s, 6.6, 1.15, 3.3, 3.6, "CLINICAL FEATURES", [
    "Hb nadir at 28-34 weeks (~10.5-11 g/dL)",
    "Asymptomatic — normal and PROTECTIVE",
    "No pallor, no tissue hypoxia",
    "Improves uteroplacental perfusion",
    "(reduces blood viscosity)",
  ], C.teal, C.lightTeal);

  infoBox(s, 10.1, 1.15, 2.9, 3.6, "LABS (KEY!)", [
    "Hb: ~10.5-11.5 g/dL (2nd T)",
    "MCV: NORMAL (81-99 fL)",
    "MCHC: NORMAL (32-35)",
    "Ferritin: NORMAL",
    "Retic: Normal/mild ↑",
    "No treatment needed",
  ], C.navy, C.lightGray);

  // Mechanism
  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.95, w:6.0, h:1.7, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.08 });
  s.addText("MECHANISM", { x:0.3, y:4.95, w:6.0, h:0.45, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  s.addText("Progesterone → Aldosterone → Na & water retention → Plasma volume ↑\nIncreased renal blood flow → ↑ EPO → ↑ RBC mass (but less than plasma expansion)", {
    x:0.4, y:5.42, w:5.8, h:1.15, fontSize:11, color:C.silver, fontFace:"Calibri", valign:"top",
  });

  s.addShape(pres.ShapeType.rect, { x:6.6, y:4.95, w:6.4, h:0.45, fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.05 });
  s.addText("KEY TEACHING POINT", { x:6.6, y:4.95, w:6.4, h:0.45, fontSize:12, bold:true, color:C.navy, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  s.addText("MCV and MCHC do NOT change in physiological anemia — this is the essential differentiating point from IDA where both fall progressively. Diagnose by exclusion: normal MCV + normal ferritin = dilutional.", {
    x:6.6, y:5.45, w:6.4, h:1.2, fontSize:11, color:C.darkGray, fontFace:"Calibri", valign:"top",
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — IDA PATHOPHYSIOLOGY + STAGES
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5B. Iron Deficiency Anemia (IDA) — Most Common Cause", C.crimson, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // Iron requirements table
  tableSlide(s,
    ["Purpose", "Average (mg)", "Range (mg)"],
    [
      ["External iron loss", "170", "150-200"],
      ["Expansion of RBC mass", "450", "200-600"],
      ["Fetal iron needs", "270", "200-370"],
      ["Placenta and cord", "90", "30-170"],
      ["Blood loss at delivery", "150", "90-310"],
      ["TOTAL REQUIREMENT", "1130", "580-1340"],
    ],
    0.3, 1.15, 5.5, [2.6, 1.4, 1.5]
  );

  // 3 Stages
  s.addShape(pres.ShapeType.rect, { x:6.1, y:1.15, w:6.9, h:0.4, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.05 });
  s.addText("THREE STAGES OF IRON DEFICIENCY", { x:6.1, y:1.15, w:6.9, h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  const stages = [
    { num:"1", title:"Pre-latent (Iron Depletion)", color:C.teal, items:["↓ Serum ferritin (depleted stores)", "Hb NORMAL | MCV NORMAL", "Iron studies NORMAL"] },
    { num:"2", title:"Latent (Iron-deficient Erythropoiesis)", color:C.gold, items:["↓ Serum iron | ↑ TIBC | ↓ % Transferrin sat.", "Hb NORMAL | MCV NORMAL", "sTfR ↑"] },
    { num:"3", title:"Overt IDA", color:C.crimson, items:["↓ Hb | ↓ MCV | ↓ MCHC", "Microcytic hypochromic smear", "Classic clinical presentation"] },
  ];

  stages.forEach((st, i) => {
    const yy = 1.65 + i * 1.5;
    s.addShape(pres.ShapeType.rect, { x:6.1, y:yy, w:0.6, h:1.3, fill:{color:st.color}, line:{color:st.color}, rectRadius:0.05 });
    s.addText("S" + st.num, { x:6.1, y:yy, w:0.6, h:1.3, fontSize:18, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
    s.addShape(pres.ShapeType.rect, { x:6.75, y:yy, w:6.25, h:1.3, fill:{color:C.white}, line:{color:"C8D6E5"} });
    s.addText(st.title, { x:6.82, y:yy+0.05, w:6.1, h:0.4, fontSize:12, bold:true, color:st.color, fontFace:"Calibri" });
    const items = st.items.map((t,j) => ({ text:t, options:{ bullet:{code:"2022"}, fontSize:11, color:C.darkGray, breakLine: j < st.items.length-1 }}));
    s.addText(items, { x:6.85, y:yy+0.45, w:6.05, h:0.8, fontFace:"Calibri", valign:"top" });
  });

  s.addText("Daily iron requirement in pregnancy: 22-23 mg/day  |  Average Indian dietary intake: ~15 mg/day  |  Shortfall must be met by supplementation", {
    x:0.3, y:6.55, w:12.7, h:0.4, fontSize:10.5, italic:true, color:C.crimson, fontFace:"Calibri", align:"center",
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — IDA: INVESTIGATIONS + SMEAR IMAGE
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5B. IDA — Clinical Features & Investigations", C.crimson, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // Clinical features box
  infoBox(s, 0.3, 1.15, 3.5, 3.2, "CLINICAL FEATURES", [
    "Fatigue, palpitations, exertional dyspnea",
    "Pica — pagophagia (ice craving) — HIGHLY characteristic",
    "Restless legs syndrome",
    "Koilonychia (spoon-shaped nails) — chronic IDA",
    "Angular stomatitis, glossitis",
    "Soft systolic flow murmur (high-output state)",
  ], C.crimson, "#FDECEA");

  // Iron studies comparison table
  tableSlide(s,
    ["Test", "Normal", "IDA", "ACD", "Thalassemia"],
    [
      ["Serum Iron", "60-170 μg/dL", "↓↓", "↓", "Normal/↑"],
      ["TIBC", "250-370 μg/dL", "↑ (>400)  ← KEY", "↓ KEY", "Normal"],
      ["% Transferrin Sat", "20-50%", "↓ (<16%)", "↓ (<30%)", "Normal/↑"],
      ["Serum Ferritin", "12-150 μg/L", "↓ (<15) ← DIAGNOSTIC", "↑ (>200)", "Normal/↑"],
      ["MCV", "80-100 fL", "↓ (<80)", "↓ (<80)", "↓↓ (<75)"],
      ["RDW", "11.5-14.5%", "↑ (>15%)", "Normal", "Normal/↑"],
    ],
    0.3, 4.5, 9.0, [1.8, 1.6, 1.6, 1.6, 1.2, 1.2]
  );

  // Smear image
  if (smearB64) {
    s.addImage({ data: smearB64, x:10.0, y:1.15, w:3.0, h:3.3 });
    s.addShape(pres.ShapeType.rect, { x:10.0, y:4.5, w:3.0, h:0.5, fill:{color:C.navy}, line:{color:C.navy} });
    s.addText("Microcytic Hypochromic Smear\n(IDA — classic appearance)", { x:10.0, y:4.5, w:3.0, h:0.5, fontSize:9, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", italic:true, margin:0 });
  }

  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.0, w:9.4, h:0.42, fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.04 });
  s.addText("Ferritin <15 μg/L = DIAGNOSTIC of IDA. Ferritin <30 μg/L with inflammation also suggests IDA (ferritin is an acute-phase reactant).", {
    x:0.35, y:4.0, w:9.3, h:0.42, fontSize:10.5, bold:true, color:C.navy, fontFace:"Calibri", valign:"middle", margin:0,
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — IDA TREATMENT
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5B. IDA — Treatment Protocol", C.crimson, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // Oral iron
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.15, w:6.0, h:0.4, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.04 });
  s.addText("1. ORAL IRON (First-line)", { x:0.3, y:1.15, w:6.0, h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  tableSlide(s,
    ["Preparation", "Elemental Fe", "Dose", "Notes"],
    [
      ["Ferrous sulfate 325 mg", "65 mg", "1 tab OD-BD", "Cheapest — standard of care"],
      ["Ferrous gluconate 300 mg", "35 mg", "1 tab BD-TDS", "Better tolerated"],
      ["Ferrous fumarate 200 mg", "65 mg", "1 tab BD", "Alternative"],
    ],
    0.3, 1.62, 6.0, [1.8, 1.0, 1.0, 2.2]
  );

  infoBox(s, 0.3, 3.5, 3.0, 3.1, "OPTIMISING ABSORPTION", [
    "Take on empty stomach",
    "Take with Vitamin C (100 mg)",
    "Avoid tea (↓ 90%), coffee (↓ 60%)",
    "Avoid calcium/antacids",
    "Alternate-day dosing = daily dosing with fewer GI effects",
    "Expected Hb rise: 1-2 g/dL per month",
  ], C.teal, C.lightTeal);

  infoBox(s, 3.5, 3.5, 2.8, 3.1, "MONITORING", [
    "Retic count ↑ within 1 week",
    "Hb rises from week 2",
    "Continue until ferritin 50-100 ng/mL",
    "Continue 3 months postpartum",
    "Side effects in 30-50%: nausea,\nconstipation, black stools (harmless)",
  ], C.navy, C.lightGray);

  // IV iron
  s.addShape(pres.ShapeType.rect, { x:6.6, y:1.15, w:6.4, h:0.4, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.04 });
  s.addText("2. IV IRON — Indications & Preparations", { x:6.6, y:1.15, w:6.4, h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  tableSlide(s,
    ["Preparation", "Dose", "Notes"],
    [
      ["Ferric Carboxymaltose (FCM)", "1000 mg single dose", "PREFERRED in pregnancy — no test dose"],
      ["Iron Sucrose", "100-200 mg/session", "Safe in pregnancy; widely used in India"],
      ["Low-MW Iron Dextran", "1000 mg over 1 hr", "Requires test dose; anaphylaxis risk"],
    ],
    6.6, 1.62, 6.4, [2.5, 1.7, 2.2]
  );

  infoBox(s, 6.6, 3.1, 6.4, 1.4, "INDICATIONS FOR IV IRON", [
    "Intolerance / non-compliance with oral iron",
    "Severe IDA in 2nd/3rd trimester (Hb <8 g/dL)",
    "Malabsorption (celiac, IBD, gastric bypass)",
    "3rd trimester — insufficient time for oral iron",
    "NOT in 1st trimester (insufficient safety data)",
  ], C.crimson, "#FDECEA");

  // Transfusion
  s.addShape(pres.ShapeType.rect, { x:6.6, y:4.6, w:6.4, h:0.4, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.04 });
  s.addText("3. BLOOD TRANSFUSION (Severe Cases)", { x:6.6, y:4.6, w:6.4, h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const txItems = [
    { text:"Hb <6 g/dL antenatally OR symptomatic severe anemia", options:{ bullet:{code:"2022"}, fontSize:11, color:C.darkGray, breakLine:true }},
    { text:"Hb <8 g/dL with active bleeding / planned surgery", options:{ bullet:{code:"2022"}, fontSize:11, color:C.darkGray, breakLine:true }},
    { text:"Hemodynamic compromise regardless of Hb", options:{ bullet:{code:"2022"}, fontSize:11, color:C.darkGray, breakLine:true }},
    { text:"Target post-transfusion Hb: 8-10 g/dL  |  Each unit pRBCs raises Hb by ~1 g/dL", options:{ bullet:{code:"2022"}, fontSize:11, color:C.crimson, bold:true }},
  ];
  s.addShape(pres.ShapeType.rect, { x:6.6, y:5.05, w:6.4, h:1.55, fill:{color:C.white}, line:{color:"C8D6E5"} });
  s.addText(txItems, { x:6.65, y:5.1, w:6.3, h:1.45, fontFace:"Calibri", valign:"top" });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — MEGALOBLASTIC ANEMIA
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5E. Megaloblastic Anemia — Folate & B12 Deficiency", C.navy, C.white);
  accentBar(s, C.gold);
  footerLine(s);

  // Folate trap mechanism
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.15, w:5.5, h:0.4, fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.04 });
  s.addText("FOLATE TRAP MECHANISM (B12 Deficiency)", { x:0.3, y:1.15, w:5.5, h:0.4, fontSize:12, bold:true, color:C.navy, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.6, w:5.5, h:2.1, fill:{color:C.white}, line:{color:"C8DCE4"} });
  s.addText(
    "B12 deficiency → Folate trapped as 5-methylTHF\n" +
    "→ ↓ THF → ↓ Thymidylate synthesis\n" +
    "→ ↓ DNA synthesis → Megaloblasts\n" +
    "→ ↑ Homocysteine → NTDs + thrombosis\n\n" +
    "Key: B12 deficiency gives identical blood picture to\nfolate deficiency but adds NEUROLOGICAL damage",
    { x:0.4, y:1.65, w:5.3, h:2.0, fontSize:11, color:C.darkGray, fontFace:"Calibri", valign:"top" }
  );

  // Comparison table
  tableSlide(s,
    ["Feature", "Folate Deficiency", "B12 Deficiency"],
    [
      ["Onset", "Rapid (months)", "Slow (years)"],
      ["Macrocytic anemia", "Yes", "Yes"],
      ["Hyperseg. neutrophils", "Yes", "Yes"],
      ["Neurological symptoms", "ABSENT", "YES — subacute combined degeneration"],
      ["Serum folate", "↓", "Normal or falsely ↑"],
      ["Serum B12", "Normal", "↓ (<200 pg/mL)"],
      ["Methylmalonic acid", "Normal", "↑ (specific for B12 def.)"],
    ],
    6.1, 1.15, 6.9, [2.3, 2.2, 2.4]
  );

  // Treatment
  infoBox(s, 0.3, 3.85, 5.5, 2.65, "TREATMENT PROTOCOL", [
    "Folate deficiency → Folic acid 5 mg/day orally",
    "Prophylaxis: 0.4 mg/day from pre-conception",
    "High-risk women: 5 mg/day (prior NTD, anticonvulsants, DM)",
    "B12 (dietary): Cyanocobalamin oral 1000-2000 mcg/day",
    "B12 (pernicious anemia/malabsorption): IM cyanocobalamin 1000 mcg/day × 7d → weekly × 4 wks → monthly",
    "Continue B12 through pregnancy and postpartum",
  ], C.teal, C.lightTeal);

  // Critical warning
  s.addShape(pres.ShapeType.rect, { x:6.1, y:4.85, w:6.9, h:1.6, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.08 });
  s.addText("⚠  CRITICAL WARNING", { x:6.2, y:4.88, w:6.7, h:0.45, fontSize:15, bold:true, color:C.gold, fontFace:"Calibri", valign:"middle" });
  s.addText(
    "NEVER give folate alone to a megaloblastic anemia patient without first checking B12!\n" +
    "Folate corrects the blood picture but worsens B12 neurological disease (subacute combined degeneration of spinal cord) — a dangerous, irreversible error. Treat empirically with BOTH if cause is unclear.",
    { x:6.2, y:5.35, w:6.7, h:1.05, fontSize:10.5, color:C.white, fontFace:"Calibri", valign:"top" }
  );
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 17 — ACD + HELLP + AIHA
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5D & 5F. Anemia of Chronic Disease · AIHA · HELLP Syndrome", C.navy, C.white);
  accentBar(s, C.teal);
  footerLine(s);

  // ACD
  infoBox(s, 0.3, 1.15, 3.9, 5.4, "ANEMIA OF CHRONIC DISEASE (ACD)", [
    "Triggered by: TB, malaria, HIV, UTI (key in India)",
    "Mechanism: IL-6 → ↑ Hepcidin → inactivates ferroportin",
    "→ Iron trapped in macrophages → ↓ serum iron",
    "Key lab: TIBC is LOW (opposite of IDA!)",
    "Ferritin ↑ (>100-200 μg/L)",
    "Usually mild-moderate normocytic normochromic",
    "TREATMENT: Address underlying cause",
    "High-dose iron NOT useful (hepcidin blocks absorption)",
    "ESA (epoetin alfa) for CRF-associated ACD",
    "Mnemonic FARM: Ferritin LOW in IDA, HIGH in ACD",
    "TIBC HIGH in IDA, LOW in ACD",
  ], C.teal, C.lightTeal);

  // AIHA
  infoBox(s, 4.4, 1.15, 4.0, 2.6, "AUTOIMMUNE HEMOLYTIC ANEMIA (AIHA)", [
    "Warm AIHA (80-90%): IgG → splenic macrophage destruction",
    "Cold AIHA (10-20%): IgM + complement → intravascular",
    "Associated: Lupus, lymphoma, EBV, methyldopa",
    "Labs: ↑ LDH, ↓ haptoglobin, ↑ indirect bili, ↑ retic",
    "Direct Coombs Test (DAT): POSITIVE — KEY diagnostic test",
    "Treatment: Steroids → IVIG → Splenectomy (2nd T if refractory)",
  ], C.navy, C.lightGray);

  // HELLP
  infoBox(s, 4.4, 3.9, 4.0, 2.65, "HELLP SYNDROME", [
    "Hemolysis + Elevated Liver enzymes + Low Platelets",
    "Part of severe preeclampsia spectrum",
    "Mechanism: Endothelial dysfunction → fibrin deposition → RBC shearing (schistocytes)",
    "Labs: ↓ Hb, ↓ Platelets (<100k), ↑ LDH, ↑ AST/ALT",
    "Smear: SCHISTOCYTES (helmet cells) — pathognomonic",
    "Treatment: DELIVERY is definitive; MgSO4; corticosteroids for FLM",
  ], C.crimson, "#FDECEA");

  // Aplastic
  infoBox(s, 8.6, 1.15, 4.4, 5.4, "APLASTIC / HYPOPLASTIC ANEMIA", [
    "Autoimmune T-cell destruction of hematopoietic stem cells",
    "Pancytopenia: ↓ Hb, ↓ WBC, ↓ Platelets (all 3 lines)",
    "Reticulocyte count ↓↓ (marrow failure)",
    "BM biopsy: HYPOCELLULAR / empty fatty marrow",
    "Camitta criteria: BM cellularity <25% + 2 of: neutrophils <500, platelets <20k, retic <1%",
    "TX: RBC + platelet transfusions (maintain Hb >8, plt >50k for delivery)",
    "ATG + Cyclosporine: Standard immunosuppression",
    "Androgens: CONTRAINDICATED (teratogenic!)",
    "No alkylating agents; BMT deferred to postpartum",
    "Meta-analysis 2025 (Arora et al., PMID 39491801):",
    "  Maternal mortality ~12%, fetal loss ~15%",
    "Deaths from infection + hemorrhage",
  ], C.navy, C.lightGray);
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 18 — THALASSEMIA
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5H. Thalassemias — India's Genetic Burden", C.teal, C.white);
  accentBar(s, C.teal);
  footerLine(s);

  // Stats bar
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.15, w:12.7, h:0.5, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.05 });
  s.addText("β-Thalassemia carrier prevalence: 3-4% of Indians (~45 million carriers)  |  ~10,000-15,000 thalassemia major children born/year in India  |  α-Thalassemia: High in NE India & tribal populations", {
    x:0.35, y:1.15, w:12.6, h:0.5, fontSize:11, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle", bold:true, margin:0,
  });

  // Types table
  tableSlide(s,
    ["Type", "Genetics", "India Prevalence", "Clinical Severity"],
    [
      ["β-Thal trait", "Heterozygous β-globin mutation", "3-4%", "Mild microcytic; no transfusion"],
      ["β-Thal major", "Homozygous", "Rare in pregnancy", "Transfusion-dependent from infancy"],
      ["α-Thal trait", "-α/αα or --/αα", "High in NE India/tribals", "Silent/mild microcytic"],
      ["HbH disease", "--/-α", "Less common", "Moderate hemolytic anemia"],
      ["Hb Barts Hydrops", "--/--", "Rare", "Fetal death in utero"],
    ],
    0.3, 1.75, 8.5, [1.8, 2.2, 1.8, 2.7]
  );

  // Investigations comparison
  tableSlide(s,
    ["Test", "β-Thal Trait", "α-Thal Trait", "IDA"],
    [
      ["Hb", "↓ (9-11)", "↓ (10-12)", "↓"],
      ["MCV", "↓↓ (<75 fL)", "↓ (<80 fL)", "↓"],
      ["Hb A2", "↑ (>3.5%) ← KEY", "Normal", "Normal"],
      ["Serum Ferritin", "Normal/↑", "Normal", "↓ (<15)"],
      ["TIBC", "Normal", "Normal", "↑"],
      ["Mentzer Index (MCV/RBC)", "<13 → Thalassemia", "<13", ">13 → IDA"],
    ],
    0.3, 4.6, 8.5, [2.2, 2.1, 2.1, 2.1]
  );

  // Key points & image
  s.addShape(pres.ShapeType.rect, { x:9.1, y:1.75, w:3.9, h:0.4, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.04 });
  s.addText("KEY MANAGEMENT POINTS", { x:9.1, y:1.75, w:3.9, h:0.4, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const thalMgmt = [
    { text:"β-Thal Trait: NO excess iron (ferritin is normal — risk of iron overload!)", options:{ bullet:{code:"2022"}, fontSize:10, color:C.crimson, bold:true, breakLine:true }},
    { text:"Routine IFA at WHO standard dose only", options:{ bullet:{code:"2022"}, fontSize:10, color:C.darkGray, breakLine:true }},
    { text:"Folic acid 5 mg/day (compensate hemolysis)", options:{ bullet:{code:"2022"}, fontSize:10, color:C.darkGray, breakLine:true }},
    { text:"Genetic counseling + partner HPLC testing", options:{ bullet:{code:"2022"}, fontSize:10, color:C.darkGray, breakLine:true }},
    { text:"HPLC: Gold standard — Hb A2 >3.5% confirms β-thal trait", options:{ bullet:{code:"2022"}, fontSize:10, color:C.teal, bold:true, breakLine:true }},
    { text:"Chelation: Deferoxamine (IV/SC) only in pregnancy. Oral chelators (deferasirox, deferiprone) are TERATOGENIC — stop pre-conception", options:{ bullet:{code:"2022"}, fontSize:10, color:C.darkGray, breakLine:true }},
    { text:"CVS at 10-12 weeks for prenatal diagnosis if both parents carriers", options:{ bullet:{code:"2022"}, fontSize:10, color:C.darkGray }},
  ];
  s.addShape(pres.ShapeType.rect, { x:9.1, y:2.2, w:3.9, h:2.3, fill:{color:C.white}, line:{color:"C8DCE4"} });
  s.addText(thalMgmt, { x:9.15, y:2.25, w:3.8, h:2.2, fontFace:"Calibri", valign:"top" });

  // Thalassemia screening flowchart image
  if (thalB64) {
    s.addImage({ data: thalB64, x:9.1, y:4.6, w:3.9, h:2.55 });
    s.addShape(pres.ShapeType.rect, { x:9.1, y:7.15, w:3.9, h:0, fill:{color:C.navy}, line:{color:C.navy} });
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  s.addText("Thalassemia Screening Algorithm (Creasy & Resnik MFM 7e)", {
    x:9.1, y:7.1, w:3.9, h:0.35, fontSize:8, italic:true, color:C.teal, fontFace:"Calibri", align:"center",
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 19 — SICKLE CELL DISEASE
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "5I. Sickle Cell Hemoglobinopathies — India Context", C.crimson, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  // India context bar
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.15, w:12.7, h:0.5, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.05 });
  s.addText("~15 million sickle cell trait carriers in India  |  ~200,000 SCA patients  |  National Sickle Cell Anaemia Elimination Mission 2023 (target: 2047)  |  Tribal belts: MP, Chhattisgarh, Jharkhand, Odisha, Maharashtra", {
    x:0.35, y:1.15, w:12.6, h:0.5, fontSize:10.5, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle", bold:true, margin:0,
  });

  // Pathophysiology
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.75, w:5.8, h:0.4, fill:{color:C.crimson}, line:{color:C.crimson}, rectRadius:0.04 });
  s.addText("PATHOPHYSIOLOGY", { x:0.3, y:1.75, w:5.8, h:0.4, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  s.addShape(pres.ShapeType.rect, { x:0.3, y:2.2, w:5.8, h:1.9, fill:{color:C.white}, line:{color:"C8D6E5"} });
  s.addText(
    "Point mutation: Glutamic acid → Valine at position 6 of β-globin chain\n" +
    "→ HbS produced → deoxygenation/oxidant stress → HbS polymerizes → RBC sickling\n\n" +
    "2 consequences:\n" +
    "  • VASO-OCCLUSION → pain crises, organ infarction, ACS, stroke\n" +
    "  • HEMOLYSIS → chronic anemia (Hb 6-9), jaundice, pigment gallstones, functional asplenia",
    { x:0.4, y:2.25, w:5.6, h:1.8, fontSize:10.5, color:C.darkGray, fontFace:"Calibri", valign:"top" }
  );

  // Pregnancy-specific risks
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    "Painful crises in 20-50% of SCA pregnancies",
    "Acute Chest Syndrome: up to 20% — most severe complication",
    "Preterm birth + FGR: up to 45% rate",
    "Pyelonephritis: ↑ (screen urine culture each trimester)",
    "VTE: ↑ risk — especially with hospitalisation",
    "Preeclampsia: ↑ risk",
  ], C.crimson, "#FDECEA");

  // Management
  infoBox(s, 6.4, 1.75, 6.6, 2.65, "ANTENATAL MANAGEMENT", [
    "Folic acid 5 mg/day (chronic hemolysis demand)",
    "Penicillin prophylaxis 500mg BD (functional asplenia)",
    "Low-dose aspirin 75-150 mg/day from 12 weeks (pre-eclampsia)",
    "LMWH thromboprophylaxis if hospitalised",
    "Serial USS: fetal growth scans 4-weekly from 24 weeks",
    "STOP hydroxyurea 3 months before conception (teratogenic)",
    "Do NOT give routine iron (may be iron-overloaded)",
    "Avoid: cold, dehydration, infections, hypoxia, oxidant drugs",
  ], C.navy, C.lightGray);

  infoBox(s, 6.4, 4.55, 3.1, 2.0, "PAINFUL CRISIS", [
    "IV fluids 2-3 L/day",
    "Oxygen (SpO2 >95%)",
    "IV morphine + paracetamol",
    "Warm packs",
    "Antibiotics if infection suspected",
    "Transfuse if Hb <6 or Hct <18%",
  ], C.teal, C.lightTeal);

  infoBox(s, 9.7, 4.55, 3.3, 2.0, "ACUTE CHEST SYNDROME", [
    "O2 + IV fluids + incentive spirometry",
    "Cephalosporin + macrolide",
    "Bronchodilators",
    "EXCHANGE TRANSFUSION",
    "Goal: HbA >50%, Hct >25%",
    "Consider ICU",
  ], C.crimson, "#FDECEA");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 20 — SECTION DIVIDER: Diagnostic Algorithm
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "06", "Diagnostic Algorithm", "Practical Flowchart — MCV-Based Approach");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 21 — DIAGNOSTIC FLOWCHART
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Practical Diagnostic Algorithm — Anemia in Pregnancy", C.navy, C.white);
  accentBar(s, C.teal);
  footerLine(s);

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  s.addText("ANEMIC PREGNANT WOMAN\n(Hb below trimester threshold)", { x:4.3, y:1.15, w:4.7, h:0.7, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  // Arrow down
  s.addShape(pres.ShapeType.line, { x:6.65, y:1.85, w:0.001, h:0.4, line:{color:C.navy, width:2} });
  s.addShape(pres.ShapeType.rect, { x:3.9, y:2.25, w:5.5, h:0.65, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.06 });
  s.addText("STEP 1: CBC + Reticulocyte count + Peripheral Smear\n→ Morphological Classification", { x:3.9, y:2.25, w:5.5, h:0.65, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  // Three columns
  const cols = [
    {
      title:"MICROCYTIC\n(MCV < 80 fL)",
      color:C.crimson, x:0.3,
      steps:[
        {label:"Iron Studies", bg:C.lightTeal},
        {label:"Ferritin + TIBC", bg:C.white},
        {label:"Ferritin <15, TIBC ↑\n→ IDA (MOST COMMON)", bg:C.crimson, light:true},
        {label:"Ferritin normal, MCV very low\n→ Thalassemia (check HPLC)", bg:C.teal, light:true},
      ]
    },
    {
      title:"NORMOCYTIC\n(MCV 80-100 fL)",
      color:C.teal, x:4.6,
      steps:[
        {label:"Reticulocyte Count", bg:C.lightTeal},
        {label:"LOW Reticulocyte\n→ Aplastic anemia / ACD\n/ Chronic renal disease", bg:C.teal, light:true},
        {label:"HIGH Reticulocyte\n→ Hemolysis", bg:C.navy, light:true},
        {label:"Check: Coombs, LDH,\nHaptoglobin, Smear\n→ AIHA / MAHA / Hemoglobinopathy", bg:C.lightGray},
      ]
    },
    {
      title:"MACROCYTIC\n(MCV > 100 fL)",
      color:C.gold, x:8.9,
      steps:[
        {label:"B12 + Folate levels", bg:C.lightTeal},
        {label:"Oval macrocytes +\nHyperseg neutrophils\n= MEGALOBLASTIC", bg:"FFF8E1"},
        {label:"Check B12 FIRST\nbefore giving folate!", bg:C.gold, light:true},
        {label:"Treat: Folate 5mg/day\nor B12 IM/oral", bg:C.white},
      ]
    },
  ];

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    s.addShape(pres.ShapeType.rect, { x:col.x, y:3.1, w:3.9, h:0.65, fill:{color:col.color}, line:{color:col.color}, rectRadius:0.06 });
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    col.steps.forEach((step, si) => {
      const yy = 3.85 + si * 0.78;
      const bgCol = step.bg;
      const txtCol = step.light ? C.white : C.darkGray;
      s.addShape(pres.ShapeType.rect, { x:col.x, y:yy, w:3.9, h:0.7, fill:{color:bgCol}, line:{color:"C8D6E5"}, rectRadius:0.04 });
      s.addText(step.label, { x:col.x+0.08, y:yy, w:3.74, h:0.7, fontSize:10, color:txtCol, fontFace:"Calibri", valign:"middle", bold:step.light });
      // Arrow
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      }
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 22 — SECTION DIVIDER: Management
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "07", "Management Flowchart", "Severity-Based Treatment · Mnemonics · Follow-Up");
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 23 — SEVERITY-BASED MANAGEMENT FLOWCHART
// ════════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Management of Anemia in Pregnancy — Severity-Based Protocol", C.navy, C.white);
  accentBar(s, C.crimson);
  footerLine(s);

  const sevs = [
    {
      label:"MILD\nHb 9-11 g/dL", color:C.teal, x:0.3,
      lines:["Oral iron (1st line)","Ferrous sulfate 65mg elem Fe/day","+ Vitamin C on empty stomach","Dietary counseling","Recheck CBC in 4 weeks","Expected Hb rise: 1-2 g/dL/month"]
    },
    {
      label:"MODERATE\nHb 7-9 g/dL", color:C.gold, x:3.55,
      lines:["Oral iron — dose as above","Escalate to IV iron if:","• Intolerant to oral","• 3rd trimester","• Inadequate response (4 wks)","Ferric carboxymaltose preferred"]
    },
    {
      label:"SEVERE\nHb < 7 g/dL", color:C.crimson, x:6.8,
      lines:["IV iron (1st choice)","Ferric carboxymaltose 1000mg IV","OR Iron sucrose 200mg × sessions","Consider blood transfusion","if Hb <6 g/dL or symptomatic","Monitor closely — fetal USS"]
    },
    {
      label:"VERY SEVERE\nHb < 5 g/dL", color:C.navy, x:10.05,
      lines:["TRANSFUSION — packed RBCs","Target Hb 8-10 g/dL","+ IV iron for stores","ICU if CCF features","Continuous fetal monitoring","Senior obstetrician involvement"]
    },
  ];

  sevs.forEach(sev => {
    s.addShape(pres.ShapeType.rect, { x:sev.x, y:1.15, w:3.0, h:0.75, fill:{color:sev.color}, line:{color:sev.color}, rectRadius:0.06 });
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    s.addShape(pres.ShapeType.rect, { x:sev.x, y:1.95, w:3.0, h:4.0, fill:{color:C.white}, line:{color:sev.color} });
    const items = sev.lines.map((t,i) => ({
      text:t,
      options:{ bullet: t.startsWith("•") ? false : {code:"2022"}, fontSize:11, color:C.darkGray, breakLine: i < sev.lines.length-1 }
    }));
    s.addText(items, { x:sev.x+0.1, y:2.0, w:2.8, h:3.9, fontFace:"Calibri", valign:"top" });
  });

  // Universal care
  s.addShape(pres.ShapeType.rect, { x:0.3, y:6.05, w:12.7, h:0.45, fill:{color:C.navy}, line:{color:C.navy}, rectRadius:0.05 });
  s.addText("ALL PATIENTS: Folic acid 0.5-5 mg/day  |  Dietary counseling  |  Treat underlying cause  |  Hemoglobinopathy screen if at risk  |  Serial USS if severe  |  Monitor CBC every 4 weeks  |  Continue iron 3 months postpartum", {
    x:0.35, y:6.05, w:12.6, h:0.45, fontSize:10, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0,
  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 24 — SPECIAL SITUATIONS + MNEMONICS
// ════════════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  addBg(s, C.offWhite);
  addHeader(s, "Special Situations · Key Mnemonics for the Seminar", C.navy, C.white);
  accentBar(s, C.gold);
  footerLine(s);

  // Special situations
  infoBox(s, 0.3, 1.15, 5.8, 5.4, "SPECIAL CLINICAL SITUATIONS", [
    "SICKLE CELL: Hydration + O2 + analgesia for crises; exchange transfusion for ACS (HbA >50%); folic acid 5mg; STOP hydroxyurea; penicillin prophylaxis",
    "",
    "THALASSEMIA TRAIT: No extra iron; genetic counseling; partner HPLC testing; deferoxamine chelation if transfusion-dependent; oral chelators TERATOGENIC",
    "",
    "APLASTIC ANEMIA: ATG + cyclosporine; RBC + platelet transfusions; NO androgens; delivery with Hb >8 and platelets >50k; maternal mortality ~12% (2025 meta-analysis)",
    "",
    "AIHA: Prednisolone → IVIG → Splenectomy (2nd trimester); rituximab limited data",
    "",
    "HELLP: Delivery is definitive; MgSO4 seizure prophylaxis; corticosteroids for FLM",
  ], C.teal, C.lightTeal);

  // Mnemonics
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  s.addText("MNEMONICS TO REMEMBER", { x:6.4, y:1.15, w:6.6, h:0.4, fontSize:14, bold:true, color:C.navy, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });

  // PHILIP mnemonic
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  s.addText("\"PHILIP\" — Causes of IDA in India", { x:6.4, y:1.63, w:6.6, h:0.4, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
  const philip = [
    ["P", "Poor diet / vegetarian"],
    ["H", "High demand (pregnancy, multiparity)"],
    ["I", "Increased losses (hookworm, menorrhagia)"],
    ["L", "Low absorption (celiac, tea with meals)"],
    ["I", "Infection (H. pylori reduces absorption)"],
    ["P", "Pre-existing deficiency (no iron stores before pregnancy)"],
  ];
  philip.forEach((row, i) => {
    const yy = 2.1 + i * 0.42;
    s.addShape(pres.ShapeType.rect, { x:6.4, y:yy, w:0.5, h:0.38, fill:{color:C.crimson}, line:{color:C.crimson} });
    s.addText(row[0], { x:6.4, y:yy, w:0.5, h:0.38, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
    s.addShape(pres.ShapeType.rect, { x:6.95, y:yy, w:6.05, h:0.38, fill:{color: i%2===0 ? C.white : C.lightTeal}, line:{color:"C8DCE4"} });
    s.addText(row[1], { x:7.05, y:yy, w:5.85, h:0.38, fontSize:11, color:C.darkGray, fontFace:"Calibri", valign:"middle" });
  });

  // FARM mnemonic
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  const farm = [
    ["F", "Ferritin — LOW in IDA, HIGH in ACD"],
    ["A", "Acid (serum iron) — LOW in BOTH"],
    ["R", "Receptors (TIBC) — HIGH in IDA, LOW in ACD"],
    ["M", "Macrophages trap iron — mechanism of ACD (hepcidin)"],
  ];
  farm.forEach((row, i) => {
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  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 25 — KEY TAKEAWAYS
// ════════════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x:1.0, y:0.95, w:W-2, h:0.06, fill:{color:C.gold}, line:{color:C.gold} });

  const takeaways = [
    [C.crimson,  "52.2% of pregnant women in India are anemic (NFHS-5) — one of the highest burdens globally"],
    [C.teal,     "IDA is the #1 cause — daily iron shortfall in Indian diet is 7-8 mg; supplementation is essential"],
    [C.gold,     "Ferritin <15 μg/L = diagnostic of IDA; Ferritin is an acute-phase reactant — use <30 in inflammation"],
    [C.crimson,  "TIBC is the KEY differentiator: HIGH in IDA vs. LOW in ACD (FARM mnemonic)"],
    [C.teal,     "NEVER give folate alone without checking B12 — risks irreversible subacute combined degeneration"],
    [C.gold,     "IV iron (ferric carboxymaltose 1000 mg) is preferred in 3rd trimester severe IDA"],
    [C.crimson,  "Thalassemia trait: NO excess iron; HPLC for diagnosis; Hb A2 >3.5% = β-thal trait"],
    [C.teal,     "Sickle cell: stop hydroxyurea 3 months pre-conception; exchange transfusion for ACS (HbA >50%)"],
    [C.gold,     "Aplastic anemia: ATG + cyclosporine; maternal mortality ~12% (2025 meta-analysis)"],
    [C.crimson,  "High Hb >14.5 g/dL is also dangerous — associated with stillbirth and FGR (paradox)"],
  ];

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  });
}

// ════════════════════════════════════════════════════════════════════════════════
// SLIDE 26 — REFERENCES / THANK YOU
// ════════════════════════════════════════════════════════════════════════════════
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  const refs = [
    "Creasy & Resnik's Maternal-Fetal Medicine, 7th Edition — Chapter 55 (Anemia in Pregnancy)",
    "Goldman-Cecil Medicine — Chapter 145 (Anemia)",
    "Harrison's Principles of Internal Medicine, 22nd Edition",
    "Rosen's Emergency Medicine, 9th Edition",
    "NFHS-5 India 2019-21 — National Family Health Survey",
    "WHO Anaemia Guidelines 2024",
    "PMID 37888841 — NFHS-5 Anemia Analysis in Indian Pregnant Women",
    "PMID 39491801 — Arora A et al., Aplastic Anemia in Pregnancy Meta-Analysis, Eur J Haematol 2025",
    "National Sickle Cell Anaemia Elimination Mission, Government of India, 2023",
  ];

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    s.addText(ref, { x:1.35, y:1.1 + i * 0.62, w:11.1, h:0.52, fontSize:10.5, color:C.silver, fontFace:"Calibri", valign:"middle" });
  });

  s.addShape(pres.ShapeType.rect, { x:0, y:H-0.5, w:W, h:0.5, fill:{color:"06102A"}, line:{color:"06102A"} });
  s.addText("Prepared for OBGYN Residency Seminar — India Focus  |  Data current as of 2024-2025", {
    x:0.3, y:H-0.5, w:W-0.6, h:0.5, fontSize:11, color:C.silver, fontFace:"Calibri", align:"center", valign:"middle", italic:true,
  });
}

// ── Write file ────────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/anemia-ppt/Anemia_in_Pregnancy_OBGYN_Seminar.pptx";
pres.writeFile({ fileName: outPath })
  .then(() => {
    const stat = require("fs").statSync(outPath);
    console.log("SUCCESS:", outPath);
    console.log("Size:", (stat.size/1024/1024).toFixed(2), "MB");
  })
  .catch(err => {
    console.error("ERROR:", err.message);
    process.exit(1);
  });