# -*- coding: utf-8 -*-
from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.style import WD_STYLE_TYPE

doc = Document()

# Page margins
for section in doc.sections:
    section.left_margin = Inches(0.8)
    section.right_margin = Inches(0.8)
    section.top_margin = Inches(0.7)
    section.bottom_margin = Inches(0.7)

# Base font sizes (LARGE for easy reading)
BODY_SIZE = Pt(16)
QUESTION_SIZE = Pt(17)
CASE_TITLE_SIZE = Pt(24)
SECTION_TITLE_SIZE = Pt(20)
DIAG_SIZE = Pt(16)

style = doc.styles["Normal"]
style.font.name = "Calibri"
style.font.size = BODY_SIZE

# Bullet list style font size
try:
    bullet_style = doc.styles["List Bullet"]
    bullet_style.font.size = BODY_SIZE
    bullet_style.font.name = "Calibri"
except KeyError:
    pass

def add_title_page():
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    run = t.add_run("OBSTETRICS & GYNAECOLOGY")
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    t2 = doc.add_paragraph()
    t2.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run2 = t2.add_run("Clinical Case Discussions — Answer Key")
    run2.bold = True
    run2.font.size = Pt(24)
    t3 = doc.add_paragraph()
    t3.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run3 = t3.add_run("30 Cases: History, Examination, Investigations, Diagnosis & Management")
    run3.italic = True
    run3.font.size = Pt(16)
    doc.add_page_break()

def add_case_heading(number, title):
    h = doc.add_paragraph()
    run = h.add_run(f"CASE {number}: {title}")
    run.bold = True
    run.font.size = CASE_TITLE_SIZE
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    h.space_after = Pt(6)
    # underline rule
    p = doc.add_paragraph()
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    pr = p.add_run("________________________________________")
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    pr.font.size = Pt(12)

def add_vignette(text):
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    run = p.add_run(text)
    run.italic = True
    run.font.size = Pt(14)
    p.paragraph_format.space_after = Pt(10)

def add_question(text):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = True
    run.font.size = QUESTION_SIZE
    run.font.color.rgb = RGBColor(0x7A, 0x00, 0x00)
    p.paragraph_format.space_before = Pt(10)
    p.paragraph_format.space_after = Pt(4)

def add_answer_lines(lines):
    """lines: list of strings. Lines starting with '- ' become bullets, others become normal paragraphs (used for short leading label like 'Diagnosis:')."""
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            p.paragraph_format.space_after = Pt(6)

def add_case(number, title, vignette, qa_list):
    add_case_heading(number, title)
    if vignette:
        add_vignette(vignette)
    for q, lines in qa_list:
        add_question(q)
        add_answer_lines(lines)
    doc.add_page_break()

add_title_page()

# =========================================================================
# CASE DATA
# =========================================================================

cases = []

# ---------- CASE 1 ----------
cases.append((1, "Ruptured Ectopic Pregnancy with Hemorrhagic Shock",
"28-year-old, 7 weeks amenorrhea, lower abdominal pain, spotting, dizziness/fainting, history of infertility treatment. Pulse 120/min, BP 88/60, cervical motion tenderness, right forniceal fullness, empty uterine cavity, right adnexal mass, free fluid in pouch of Douglas.",
[
("Discuss differential diagnosis and investigations.",
[
"- Ruptured ectopic pregnancy (most likely)",
"- Hemorrhagic corpus luteal cyst rupture",
"- Ovarian cyst torsion",
"- Incomplete / threatened abortion",
"- Acute PID / tubo-ovarian abscess",
"- Acute appendicitis",
"Investigations: Urine/serum beta-hCG, transvaginal ultrasound (empty uterus + adnexal mass + free fluid confirms diagnosis), complete blood count, blood grouping and cross-match, coagulation profile.",
]),
("How will you manage this patient?",
[
"This patient is hemodynamically unstable (pulse 120, BP 88/60) — this is a surgical emergency.",
"- Resuscitate first: two wide-bore IV lines, crystalloids, cross-matched blood transfusion, oxygen",
"- Do NOT delay for further imaging once ectopic with instability is confirmed",
"- Emergency laparotomy or laparoscopy with salpingectomy",
"- Give Anti-D immunoglobulin if Rh-negative",
"- Continue monitoring vitals and urine output postoperatively",
]),
("What are other forms of ectopic pregnancy and how are they diagnosed and managed?",
[
"- Tubal (95%, mostly ampullary): diagnosed by TVS; managed by expectant/medical (methotrexate) if stable and unruptured, or surgery (salpingectomy/salpingostomy) if ruptured or unstable",
"- Cervical: USG shows hourglass uterus, empty uterine cavity, gestational sac in cervix; managed with methotrexate, uterine artery embolization, cerclage/balloon tamponade, rarely hysterectomy",
"- Cesarean scar pregnancy: sac seen in anterior lower segment scar on USG; managed with methotrexate or surgical excision",
"- Ovarian: diagnosed using Spiegelberg criteria; managed surgically (wedge resection/oophorectomy)",
"- Interstitial/cornual: 'interstitial line sign' on USG; higher risk of massive bleeding; managed by cornual resection or methotrexate if stable",
"- Abdominal: diagnosed by USG/MRI; managed by laparotomy, placenta often left in situ if densely adherent",
"- Heterotopic (coexisting intrauterine + ectopic): more common with ART; managed by surgical removal of ectopic while preserving the intrauterine pregnancy",
]),
]))

# ---------- CASE 2 ----------
cases.append((2, "Uterine Rupture in Labour (Previous Cesarean Scar)",
"28-year-old G2P1L1 with previous one lower segment cesarean section, 39 weeks in labour. Sudden severe abdominal pain, cessation of contractions, vaginal bleeding, absent fetal movements. Pulse 120, BP 90/60, pallor, generalized abdominal tenderness, fetal parts easily palpable, uterus poorly defined, FHS absent. USG: fetus lying outside uterine cavity with hemoperitoneum.",
[
("What is the diagnosis?",
["Uterine (scar) rupture during trial of labour after previous cesarean section, with fetal extrusion into the abdominal cavity, intrauterine fetal death, and hemoperitoneum."]),
("What are the risk factors?",
[
"- Previous cesarean section or other uterine surgery (especially classical incision or multiple scars)",
"- Short inter-delivery interval (less than 18-24 months)",
"- Induction/augmentation of labour with oxytocin or prostaglandins",
"- Obstructed labour, malpresentation",
"- Grand multiparity",
"- Injudicious instrumental delivery",
"- Uterine anomalies, placenta accreta spectrum",
"- Excessive uterine distension (polyhydramnios, multiple gestation)",
]),
("What are the clinical features suggestive of this condition?",
[
"- Sudden severe abdominal pain with cessation of previously good contractions",
"- Vaginal bleeding",
"- Maternal tachycardia and hypotension (shock)",
"- Abdominal tenderness with easily palpable fetal parts (loss of uterine contour)",
"- Regression of the presenting part on vaginal exam",
"- Absent fetal heart sounds",
"- Scar tenderness or dehiscence",
"- 'Fetus outside uterus' with hemoperitoneum on USG",
]),
("Outline the management.",
[
"- Immediate resuscitation: IV fluids, blood transfusion, oxygen",
"- Emergency laparotomy without delay",
"- Delivery of the fetus (already dead in this case)",
"- Repair of the uterine tear vs subtotal/total hysterectomy, depending on extent of the tear and desire for future fertility",
"- Ensure complete hemostasis",
"- Broad-spectrum antibiotics",
"- Counsel regarding future pregnancies — elective cesarean before onset of labour recommended",
]),
]))

# ---------- CASE 3 ----------
cases.append((3, "Bartholin's Cyst",
"35-year-old P3L3 woman with a gradually progressive, painless swelling in the left vulvar region for 6 months. No fever, dyspareunia, vulvar pain, or discharge. Exam: 4x3 cm cystic, fluctuant, non-tender swelling at the posterolateral vaginal introitus (5 o'clock position); overlying skin healthy.",
[
("What is the most likely diagnosis?",
["Bartholin's cyst (a non-tender cystic swelling at the posterolateral vaginal introitus, classically at the 4-5 or 7-8 o'clock position, is the hallmark presentation)."]),
("What are the differential diagnoses?",
[
"- Bartholin's abscess (if tender/inflamed — not present here)",
"- Epidermal inclusion cyst",
"- Gartner's duct cyst",
"- Vulvar lipoma",
"- Hidradenoma",
"- Labial hernia",
"- Vulvar varicosities",
"- Bartholin gland carcinoma (rare — consider especially in women over 40 years)",
]),
("Discuss the management options.",
[
"- Small, asymptomatic cysts: observation",
"- Symptomatic/large cysts: marsupialization is the treatment of choice (preserves gland function)",
"- Word catheter insertion as an alternative",
"- Excision of the gland if recurrent, or if malignancy is suspected (especially age over 40)",
"- Incision and drainage for an infected abscess (higher recurrence rate than marsupialization)",
"- Biopsy if the lesion is atypical or the patient is older, to exclude carcinoma",
]),
]))

# ---------- CASE 4 ----------
cases.append((4, "Secondary Amenorrhea due to PCOS",
"25-year-old woman with absence of menstruation for 8 months, irregular cycles since menarche, weight gain, and facial hair growth. BMI 33 kg/m2, hirsutism present. Pregnancy test negative, TSH normal, prolactin normal, TVS shows polycystic ovaries.",
[
("What are the causes of secondary amenorrhea?",
[
"- Pregnancy (always exclude first)",
"- Hypothalamic: functional (stress, weight loss, excessive exercise)",
"- Pituitary: hyperprolactinemia/prolactinoma, Sheehan syndrome, empty sella",
"- Ovarian: PCOS, premature ovarian insufficiency, ovarian tumors",
"- Thyroid dysfunction (hypo- or hyperthyroidism)",
"- Adrenal: late-onset congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumor",
"- Uterine: Asherman syndrome (intrauterine adhesions)",
"- Physiological: lactation, menopause",
"- Drug-induced: antipsychotics, contraceptives",
]),
("How will you evaluate and manage this patient?",
[
"Evaluation: Pregnancy test (negative), TSH (normal), prolactin (normal), androgen levels (testosterone/DHEAS), TVS (shows polycystic ovaries). Diagnosis here is PCOS by the Rotterdam criteria (2 of 3: oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovarian morphology).",
"Management:",
"- Lifestyle modification (weight loss, diet, exercise) is first-line",
"- Combined oral contraceptives or cyclic progestins for menstrual regulation",
"- COCs +/- anti-androgens (e.g., spironolactone) for hirsutism",
"- If fertility desired: clomiphene citrate or letrozole as first-line ovulation induction, metformin as an adjunct (especially with insulin resistance), gonadotropins or laparoscopic ovarian drilling as second-line",
"- Screen for metabolic syndrome (OGTT, lipid profile)",
"- Long-term endometrial protection, as unopposed estrogen raises hyperplasia risk",
]),
]))

# ---------- CASE 5 ----------
cases.append((5, "Third-Degree Uterovaginal Prolapse",
"58-year-old multiparous postmenopausal woman with something coming out per vaginum for 8 years, difficulty walking, urinary frequency, stress incontinence, worse on straining. Third-degree uterovaginal prolapse with cystocele, rectocele, and a decubitus ulcer. Uterus normal size, no adnexal mass.",
[
("Discuss etiopathogenesis and classification of prolapse.",
[
"Etiopathogenesis: Weakening of pelvic floor support (levator ani, endopelvic fascia, uterosacral/cardinal ligaments) due to vaginal childbirth trauma (prolonged labour, instrumental delivery, macrosomia), aging and estrogen deficiency, chronic raised intra-abdominal pressure (chronic cough, constipation, heavy lifting, obesity, pelvic mass), congenital connective tissue weakness.",
"Classification:",
"- Traditional: First degree (cervix descends within vagina), Second degree (cervix reaches introitus), Third degree/procidentia (entire uterus outside introitus)",
"- POP-Q staging (Stage 0 to IV) — the current standard, based on measurements relative to the hymen",
"- By compartment: anterior (cystocele), posterior (rectocele/enterocele), apical (uterine/vault prolapse)",
]),
("How will you manage this patient surgically and conservatively?",
[
"Conservative: Treat the decubitus ulcer first with local care and topical estrogen before any surgery; pessary if surgery is deferred or the patient is unfit; pelvic floor (Kegel) exercises; weight reduction; treat chronic cough/constipation.",
"Surgical (appropriate here — postmenopausal, third-degree prolapse, no desire for fertility):",
"- Vaginal hysterectomy with pelvic floor repair (anterior colporrhaphy + posterior colpoperineorrhaphy) — standard definitive surgery",
"- Sacrospinous fixation or Manchester repair if uterine preservation desired",
"- Colpocleisis (Le Fort's procedure) if unfit for major surgery",
"- Address stress incontinence with a mid-urethral sling if confirmed on urodynamic evaluation",
]),
]))

# ---------- CASE 6 ----------
cases.append((6, "Hyperprolactinemia",
"25-year-old woman presents with infertility and amenorrhea, complains of milky nipple discharge. Serum prolactin elevated.",
[
("Causes of hyperprolactinemia.",
[
"- Physiological: pregnancy, lactation, stress, sleep, nipple stimulation",
"- Drug-induced: antipsychotics/dopamine antagonists, metoclopramide, antidepressants, verapamil, opioids",
"- Pathological: pituitary prolactinoma (micro/macroadenoma), hypothyroidism (raised TRH), PCOS",
"- Chronic renal failure, cirrhosis",
"- Chest wall lesions or stimulation",
"- Empty sella, other pituitary/stalk lesions (stalk effect)",
"- Idiopathic",
]),
("Management.",
[
"- Confirm with repeat serum prolactin; rule out pregnancy and hypothyroidism (TSH); check macroprolactin",
"- MRI pituitary if a pituitary source is suspected",
"- Medical (first-line): dopamine agonists — cabergoline preferred (more effective, better tolerated); bromocriptine is an alternative, preferred if pregnancy is desired imminently due to longer safety data",
"- Dopamine agonists normalize prolactin, shrink the tumor, and restore ovulation/fertility",
"- Surgery (transsphenoidal resection): reserved for dopamine agonist-resistant/intolerant cases, or macroadenoma with visual field compromise",
"- Monitor prolactin and tumor size serially; dopamine agonists are usually stopped once pregnancy is confirmed (with monitoring for macroadenoma growth)",
]),
]))

# ---------- CASE 7 ----------
cases.append((7, "Large Benign Ovarian Cyst — Adnexal Mass Evaluation",
"36-year-old nulliparous woman with gradually increasing abdominal distension for 6 months, dull pain, early satiety, no menstrual irregularity, no weight loss. Large abdominopelvic cystic mass equivalent to 28 weeks size. USG: 18x16 cm unilocular thin-walled left ovarian cyst, no solid component/papillary projections/septations. Tumor markers (CA-125, CEA, AFP, beta-hCG) all normal/negative.",
[
("What are the differential diagnoses of a large adnexal mass?",
[
"- Benign ovarian neoplasm (serous/mucinous cystadenoma, mature cystic teratoma)",
"- Functional ovarian cyst",
"- Endometrioma",
"- Malignant ovarian tumor (epithelial, germ cell, sex cord-stromal)",
"- Tubo-ovarian abscess",
"- Hydrosalpinx / paratubal cyst",
"- Pedunculated uterine fibroid",
"- Non-gynecological causes: mesenteric cyst, retroperitoneal tumor, distended bladder/bowel",
]),
("How will you evaluate malignancy risk and plan management?",
[
"Reassuring features here: unilocular, thin-walled, no solid component/papillary projections/septations on USG, and normal CA-125/CEA/AFP with negative beta-hCG — this favors a benign cystadenoma.",
"- Use the Risk of Malignancy Index (RMI = USG score x menopausal status score x CA-125) or IOTA simple rules/ADNEX model for further risk stratification",
"- Given low RMI, proceed to elective surgical management",
"- Laparoscopic or open ovarian cystectomy with intraoperative frozen section",
"- Convert to full staging laparotomy if malignancy is found intraoperatively",
"- Preserve fertility given nulliparity if confirmed benign; send specimen for histopathology",
]),
]))

# ---------- CASE 8 ----------
cases.append((8, "Endometriosis with Infertility",
"29-year-old nulliparous woman with severe dysmenorrhea, deep dyspareunia, and infertility for 4 years. Pain begins 2-3 days before menstruation. Bimanual exam: retroverted fixed uterus, bilateral uterosacral ligament nodularity, left adnexal tenderness, restricted mobility. USG: left ovarian cyst with homogeneous ground-glass appearance, 5 cm.",
[
("Discuss staging and investigations for endometriosis.",
[
"Staging: Revised American Society for Reproductive Medicine (rASRM) staging — Stage I (minimal), II (mild), III (moderate), IV (severe) — based on size/depth of implants, adhesions, and endometrioma presence, scored at laparoscopy.",
"Investigations:",
"- Transvaginal ultrasound (best initial test; shows 'ground-glass' homogeneous echogenic cyst, as seen here)",
"- MRI (better for deep infiltrating disease, uterosacral/rectovaginal involvement)",
"- CA-125 (may be elevated but is nonspecific)",
"- Diagnostic laparoscopy with biopsy (gold standard for definitive diagnosis and staging)",
]),
("How will you manage this patient considering fertility wishes?",
[
"Since fertility is desired, avoid prolonged hormonal suppression, which does not improve fertility.",
"- Laparoscopic excision/cystectomy of the endometrioma (greater than 3-4 cm) plus adhesiolysis — improves fertility chances (counsel on risk of reduced ovarian reserve from surgery)",
"- Attempt natural conception for about 6 months post-surgery, or proceed directly to ART (IUI/IVF) given the 4-year infertility duration already",
"- Medical therapy (GnRH agonists, OCPs, progestins) is for pain relief only, not used while actively trying to conceive; a short pre-IVF GnRH agonist 'down-regulation' protocol may improve IVF outcomes",
"- If severe disease or surgery fails, proceed directly to IVF",
]),
]))

# ---------- CASE 9 ----------
cases.append((9, "Advanced Cervical Carcinoma (Postmenopausal Bleeding with Parametrial Involvement)",
"68-year-old postmenopausal woman with persistent vaginal bleeding, foul-smelling watery discharge, and pelvic pain for 8 months. Anorexia, weight loss. Menopause 15 years ago. Mild lower abdominal distension. Speculum: blood-stained discharge. Bimanual: cervix enlarged to about 5 cm, uterus displaced anteriorly, fullness/restricted mobility in the left parametrium.",
[
("What is the likely diagnosis and how should it be worked up?",
[
"The combination of postmenopausal bleeding, foul watery discharge, weight loss/anorexia, an enlarged cervix, and parametrial fullness with restricted mobility strongly suggests advanced cervical carcinoma (at least Stage IIB/III with parametrial spread).",
"- Clinical staging: per-speculum and bimanual/rectal exam under anesthesia",
"- Cervical biopsy/colposcopy-directed biopsy for histological confirmation",
"- MRI pelvis for local staging (parametrial, vaginal, pelvic wall extent)",
"- Cystoscopy and proctoscopy to check for bladder/rectal involvement",
"- CT chest/abdomen or PET-CT to assess for nodal and distant metastases",
"- Management depends on final stage — chemoradiation (concurrent cisplatin-based chemotherapy with pelvic radiotherapy) is standard for locally advanced disease; surgery is not typically feasible once parametrium is involved",
]),
]))

# ---------- CASE 10 ----------
cases.append((10, "Endometrial Carcinoma Risk — Postmenopausal Bleeding in an Obese Diabetic Patient",
"62-year-old woman with postmenopausal bleeding for 3 months (intermittent, scanty, painless), menopause 12 years ago, occasional watery discharge, abdominal pain for 10 years, type 2 diabetes, hypertension, obese (BMI 34). Mild pallor. Cervix healthy, mild blood-stained discharge, uterus slightly enlarged (8-week size), mobile, no adnexal mass.",
[
("What is the likely diagnosis and how should it be worked up?",
[
"This patient's risk profile — obesity, type 2 diabetes, hypertension, postmenopausal bleeding — is the classic picture of Type-1 (estrogen-dependent) endometrial carcinoma, the most important differential for any postmenopausal bleeding.",
"- Transvaginal ultrasound first to measure endometrial thickness (greater than 4-5 mm in a postmenopausal woman warrants further evaluation)",
"- Endometrial biopsy or hysteroscopy with directed biopsy — the gold standard for tissue diagnosis",
"- If malignancy confirmed: MRI pelvis for staging, CA-125, chest imaging",
"- Management once confirmed: total hysterectomy with bilateral salpingo-oophorectomy and staging lymphadenectomy is standard for early-stage disease, with adjuvant radiotherapy/chemotherapy per stage and risk factors",
]),
]))

# ---------- CASE 11 ----------
cases.append((11, "Pelvic Inflammatory Disease / Tubo-Ovarian Abscess",
"34-year-old multiparous woman with chronic lower abdominal pain, dyspareunia, and foul vaginal discharge for 8 months. History of unsafe abortion 1 year back. Irregular fever. Mild pallor, low-grade fever. Speculum: mucopurulent cervical discharge. Bimanual: cervical motion tenderness, bilateral adnexal tenderness, restricted uterine mobility. USG: bilateral tubo-ovarian masses.",
[
("How will you investigate this patient?",
[
"- Complete blood count (leukocytosis)",
"- CRP/ESR (elevated; useful to monitor treatment response)",
"- Pregnancy test",
"- Endocervical swabs/NAAT for gonorrhea and chlamydia",
"- Wet mount/gram stain of vaginal discharge",
"- HIV, syphilis, hepatitis B screening",
"- Transvaginal/pelvic ultrasound (confirms tubo-ovarian masses, as seen here)",
"- CA-125 (can be elevated in TOA, mimicking malignancy — needs clinical correlation)",
"- Diagnostic laparoscopy if diagnosis is unclear or there is no response to treatment",
"- Blood cultures if septic",
]),
("What is syndromic approach to STI?",
[
"The syndromic approach treats based on the clinical syndrome (presenting symptom complex) without waiting for laboratory confirmation, covering the most likely pathogens for that syndrome.",
"- For lower abdominal pain/PID syndrome: treat empirically for gonorrhea, chlamydia, and anaerobes/gram-negatives",
"- WHO syndromic management uses flowcharts based on the presenting complaint (urethral discharge, vaginal discharge, genital ulcer, lower abdominal pain) to select a regimen covering all likely organisms",
"- Includes partner/contact tracing and treatment, plus health education and condom promotion",
"- Particularly useful in resource-limited settings without ready access to laboratory testing",
]),
("Discuss long-term complications and management.",
[
"Complications: Chronic pelvic pain, tubal factor infertility, recurrent PID, increased risk of ectopic pregnancy (due to tubal damage), Fitz-Hugh-Curtis syndrome (perihepatitis), rupture of a tubo-ovarian abscess leading to sepsis/peritonitis.",
"Management:",
"- Hospitalize given the tubo-ovarian abscess",
"- IV broad-spectrum antibiotics (e.g., IV cefoxitin/cefotetan plus doxycycline, or clindamycin plus gentamicin) covering anaerobes, gram-negatives, and gonococcus/chlamydia",
"- Continue for 24-48 hours, then step down to oral therapy to complete a 14-day course",
"- If no response in 48-72 hours, or abscess greater than 7-8 cm, perform image-guided or surgical drainage",
"- Treat the partner; counsel on future fertility implications and increased ectopic pregnancy risk",
"- Screen and treat for other STIs",
]),
]))

# ---------- CASE 12 ----------
cases.append((12, "Diminished Ovarian Reserve",
"35-year-old woman presents with primary infertility. AMH low, antral follicle count (AFC) reduced.",
[
("What are ovarian reserve tests?",
[
"- Day 2-3 serum FSH and estradiol",
"- Anti-Mullerian hormone (AMH) — the best single marker of ovarian reserve",
"- Antral follicle count (AFC) on transvaginal ultrasound",
"- Clomiphene citrate challenge test (historic, less used now)",
"- Inhibin B and ovarian volume (less commonly used)",
]),
("Management of diminished ovarian reserve.",
[
"- Counsel the patient regarding reduced natural fertility and reduced IVF success rates",
"- Do not delay fertility treatment — expedite referral to assisted reproduction",
"- Ovulation induction plus IUI if reserve reduction is mild and tubes/semen parameters are normal",
"- IVF with an individualized stimulation protocol (higher gonadotropin doses, antagonist protocols); earlier referral to ART is advised",
"- Consider adjuncts such as DHEA/CoQ10 (evidence is limited)",
"- Donor oocyte IVF if reserve is severely reduced or response is poor",
"- General health optimization: lifestyle measures, weight management, avoid smoking",
]),
]))

# ---------- CASE 13 ----------
cases.append((13, "Advanced Ovarian Malignancy",
"58-year-old postmenopausal woman with progressive abdominal distension, loss of appetite, and early satiety for 5 months, no history of postmenopausal bleeding. Unintentional weight loss of about 7 kg over 6 months. Distended abdomen with free fluid, pelvic-abdominal mass approximately 20-week size with restricted mobility, bilateral adnexal fullness, fullness in the pouch of Douglas.",
[
("What is the likely diagnosis and how should it be worked up and managed?",
[
"The combination of ascites, a large pelvic-abdominal mass, bilateral adnexal fullness, weight loss, and restricted mobility in a postmenopausal woman is highly suspicious for advanced epithelial ovarian carcinoma with peritoneal spread.",
"- CA-125 and HE4 (calculate ROMA score); CEA, CA 19-9 if mucinous histology is suspected",
"- CT abdomen and pelvis (or MRI) to assess extent of disease, omental/peritoneal involvement, and resectability",
"- Ascitic fluid aspiration for cytology",
"- Chest imaging to exclude pleural effusion/metastasis",
"- Management: staging laparotomy with maximal cytoreductive surgery (total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node assessment, debulking of visible disease) followed by adjuvant chemotherapy (platinum/taxane-based)",
"- If disease is too extensive for primary complete cytoreduction, neoadjuvant chemotherapy followed by interval debulking surgery is preferred",
]),
]))

# ---------- CASE 14 ----------
cases.append((14, "Premature Ovarian Insufficiency (POI)",
"34-year-old woman presents with infertility and irregular periods. FSH elevated, AMH very low, AFC reduced.",
[
("Define premature ovarian insufficiency.",
["Premature Ovarian Insufficiency is loss of normal ovarian function before age 40, characterized by menstrual disturbance (oligomenorrhea or amenorrhea) for at least 4 months, with two FSH levels greater than 25 IU/L measured more than 4 weeks apart, associated with low AMH and reduced antral follicle count — reflecting a depleted or dysfunctional follicular pool, as seen in this patient."]),
("Management and fertility options.",
[
"Confirm diagnosis with repeat FSH, karyotype (to exclude Turner syndrome/mosaicism), FMR1 premutation testing (Fragile X), and autoimmune workup (thyroid, adrenal antibodies).",
"Management:",
"- Hormone replacement therapy (estrogen plus progestin) until the natural age of menopause, to prevent osteoporosis and cardiovascular disease and manage vasomotor symptoms",
"- Bone density (DEXA) monitoring with calcium and vitamin D supplementation",
"Fertility options:",
"- Spontaneous conception is rare (about 5-10%) but possible — contraception should still be discussed if pregnancy is not desired",
"- Donor oocyte IVF is the most successful fertility option for those wishing to conceive",
"- Own-oocyte IVF success is very low given depleted reserve",
"- Adoption/surrogacy counselling and psychological support as needed",
]),
]))

# ---------- CASE 15 ----------
cases.append((15, "Vulvar Carcinoma",
"65-year-old postmenopausal woman with chronic vulvar pruritus and a non-healing vulvar ulcer for 8 months. A 2 cm ulcerative lesion with indurated margins on the right labium majus. No palpable inguinal lymphadenopathy.",
[
("What is the most likely diagnosis?",
["Vulvar carcinoma (squamous cell carcinoma), given the chronic pruritus and a non-healing, indurated ulcer in a postmenopausal woman."]),
("What is the commonest histological subtype of vulvar malignancy?",
["Squamous cell carcinoma accounts for more than 90% of vulvar cancers."]),
("What is the gold-standard diagnostic investigation?",
["Vulvar biopsy (wedge or punch biopsy of the lesion, including its edge) for histopathological confirmation."]),
]))

# ---------- CASE 16 ----------
cases.append((16, "Gestational Diabetes with Fetal Macrosomia and Polyhydramnios",
"34-year-old primigravida at 34 weeks gestation, referred to high-risk clinic for persistently elevated glucose despite dietary modification. Diagnosed with GDM at 28 weeks. Home glucose records: fasting 105-115 mg/dL, postprandial 150-170 mg/dL for 3 weeks. USG at 33 weeks: estimated fetal weight above 90th percentile, mild polyhydramnios (AFI 27 cm). Fundal height 37 cm at 33 weeks (large for dates), FHR 144/min.",
[
("How should this patient be managed?",
[
"Glucose targets remain above goal despite dietary modification for 3 weeks — this is diet-failure GDM and requires escalation to pharmacotherapy.",
"- Start insulin (first-line pharmacological agent in pregnancy) or metformin per local protocol",
"- Increase fetal surveillance: serial growth scans to monitor macrosomia, AFI monitoring, non-stress tests/biophysical profile",
"- Continue self-monitoring of blood glucose 4 times daily (fasting + postprandial)",
"- Plan delivery around 38-39 weeks; consider earlier or elective cesarean if estimated fetal weight becomes significantly large, given the risk of shoulder dystocia",
"- Counsel regarding risks of macrosomia: shoulder dystocia, birth trauma, neonatal hypoglycemia",
"- Postpartum: reclassify glucose status with a 75g OGTT at 6-12 weeks postpartum",
]),
]))

# ---------- CASE 17 ----------
cases.append((17, "Severe Iron-Deficiency Anemia in Pregnancy",
"24-year-old primigravida at 32 weeks gestation with progressively worsening easy fatigability, generalized asthenia, exertional dyspnea for 2 months. Poor compliance with prescribed antenatal iron. Marked conjunctival and palmar pallor. Hb 7.2 g/dL, MCV 68 fl, microcytic hypochromic anemia on peripheral smear, serum ferritin 8 ng/mL, stool negative for ova and cysts.",
[
("What is the provisional and definitive diagnosis?",
["Provisional diagnosis: severe anemia in pregnancy. Definitive diagnosis: iron-deficiency anemia (confirmed by microcytic hypochromic picture, low MCV, low serum ferritin, and exclusion of hookworm infestation/other causes of chronic blood loss or malabsorption)."]),
("How is anemia in pregnancy classified according to WHO criteria?",
[
"- Hb 11 g/dL or more: Normal",
"- Hb 10 to 10.9 g/dL: Mild anemia",
"- Hb 7 to 9.9 g/dL: Moderate anemia",
"- Hb less than 7 g/dL: Severe anemia (this patient, Hb 7.2, is at the severe end)",
"- Hb less than 4 g/dL: Very severe anemia",
]),
("Discuss the etiopathogenesis of iron deficiency anemia in pregnancy.",
[
"- Increased fetoplacental iron demand in pregnancy (approximately 1000 mg total iron required) exceeding dietary intake and absorption",
"- Poor dietary iron intake, as in this patient",
"- Pre-existing depleted iron stores (from menstrual blood loss, multiparity)",
"- Poor compliance with iron supplementation",
"- Reduced iron absorption (achlorhydria, helminthic infection, GI disorders)",
"- Physiological hemodilution of pregnancy superimposed on a true iron deficit",
]),
("Enumerate the maternal, fetal, and neonatal complications of anemia in pregnancy. Outline the management protocol for this patient.",
[
"Maternal: increased susceptibility to infection, cardiac decompensation/failure, poor tolerance of blood loss at delivery, increased risk of severe postpartum hemorrhage complications, subinvolution, puerperal sepsis, increased maternal mortality.",
"Fetal: intrauterine growth restriction, preterm birth, fetal hypoxia, low birth weight.",
"Neonatal: neonatal anemia/depleted iron stores, impaired cognitive and neurodevelopmental outcomes, increased perinatal mortality.",
"Management:",
"- IV iron (iron sucrose or ferric carboxymaltose) given the severity and documented non-compliance with oral iron — allows rapid replenishment of stores",
"- Reserve blood transfusion for very severe anemia with cardiac compromise, or if delivery is imminent",
"- Monitor Hb response in 2-3 weeks",
"- Plan delivery at a well-equipped center with blood bank backup given PPH risk",
"- Active management of the third stage of labour to minimize blood loss",
"- Continue iron supplementation postpartum",
]),
]))

# ---------- CASE 18 ----------
cases.append((18, "Genital Warts (Condyloma Acuminata)",
"28-year-old sexually active woman with multiple vulvar growths and persistent pruritus for 4 months. No pain or bleeding. Multiple exophytic, papillomatous, cauliflower-like lesions over the labia majora and perineal region.",
[
("What is the most likely diagnosis?",
["Condyloma acuminata (genital warts) due to HPV infection — the exophytic, papillomatous, cauliflower-like lesion morphology is characteristic."]),
("Identify the causative viral subtypes.",
["Low-risk HPV types 6 and 11 cause the great majority of genital warts. High-risk oncogenic types (16 and 18) can coexist and are associated with dysplasia/cervical cancer, though they do not typically cause the warty lesions themselves."]),
("Discuss the available treatment modalities.",
[
"Patient-applied: topical podophyllotoxin, imiquimod cream, sinecatechins (green tea extract ointment).",
"Provider-administered: cryotherapy (liquid nitrogen), trichloroacetic acid (TCA), surgical excision, electrocautery, or CO2 laser ablation for extensive lesions.",
"Adjuncts: partner evaluation and treatment, safe-sex counselling, HPV vaccination (limited therapeutic benefit but helps prevent infection with other types), and cervical (Pap smear) screening given the HPV association with cervical dysplasia.",
]),
]))

# ---------- CASE 19 ----------
cases.append((19, "Stable Unruptured Tubal Ectopic Pregnancy",
"26-year-old G2P1L1 woman with 6 weeks amenorrhea, lower abdominal pain for 3 days, and scant per-vaginal bleeding for 1 day. Hemodynamically stable, pulse 84, BP 110/70, mild right iliac fossa tenderness, cervical motion tenderness. Urine pregnancy test positive, serum beta-hCG 2800 mIU/mL. TVS: empty uterine cavity with a right adnexal gestational sac.",
[
("What is the most likely diagnosis?",
["Right tubal ectopic pregnancy, unruptured, in a hemodynamically stable patient."]),
("Enumerate the risk factors.",
[
"- Previous ectopic pregnancy",
"- Pelvic inflammatory disease / tubal damage",
"- Previous tubal surgery or sterilization",
"- Infertility treatment / assisted reproductive technology (IVF)",
"- Smoking",
"- Intrauterine device use",
"- Previous pelvic or abdominal surgery",
"- Endometriosis",
"- Advanced maternal age",
]),
("What additional investigations would you advise?",
[
"- Serial serum beta-hCG 48 hours apart (a suboptimal rise, less than about 35% in 48 hours, supports ectopic pregnancy)",
"- Repeat transvaginal ultrasound to confirm findings and monitor for signs of impending rupture",
"- Complete blood count/hemoglobin",
"- Blood group and Rh typing (Anti-D if Rh-negative)",
"- Renal and liver function tests (baseline before methotrexate if medical management is considered)",
]),
("What are the eligibility criteria for medical management?",
[
"- Hemodynamically stable, unruptured ectopic pregnancy",
"- No significant pain",
"- Serum beta-hCG ideally less than 5000 mIU/mL (better outcomes below 1500-3000)",
"- Gestational sac size less than 3.5-4 cm",
"- No fetal cardiac activity",
"- Normal renal and liver function, no blood dyscrasia",
"- Not breastfeeding, and able/willing to comply with follow-up",
"- No coexisting desired intrauterine pregnancy",
]),
("Describe the follow-up protocol.",
[
"- Serum beta-hCG on day 4 and day 7 after methotrexate (expect at least a 15% decline between day 4 and day 7)",
"- If decline is inadequate, a repeat dose (up to 2-3 doses total) may be required, or conversion to surgical management",
"- Continue weekly beta-hCG monitoring until it becomes undetectable (less than 5 mIU/mL)",
"- Avoid NSAIDs, folic acid supplements, alcohol, and sun exposure during treatment",
"- Avoid pregnancy for at least 3 months after methotrexate (teratogenic folate-antagonist effect)",
"- Monitor closely for signs of rupture or worsening pain throughout follow-up, which would require urgent surgical intervention",
]),
]))

# ---------- CASE 20 ----------
cases.append((20, "Eclampsia with HELLP Overlap",
"22-year-old primigravida at 36 weeks gestation, brought to the emergency department after two episodes of generalized tonic-clonic seizures, with headache and visual disturbances for 2 days. Drowsy but arousable, pulse 110, BP 180/120, pedal edema ++. Urine protein +4, platelets 100,000/mm3, LFTs mildly deranged.",
[
("What is the diagnosis and how should this patient be managed?",
[
"Diagnosis: Eclampsia (seizures in the setting of severe pre-eclampsia — BP 180/120, proteinuria +4), with overlapping features of HELLP syndrome (thrombocytopenia, deranged LFTs).",
"Management:",
"- Airway protection, left lateral position, oxygen supplementation",
"- Magnesium sulfate (Pritchard regimen — loading plus maintenance dose) for seizure control and to prevent recurrent seizures; monitor deep tendon reflexes, respiratory rate, and urine output for toxicity",
"- Control BP with IV labetalol or hydralazine, or oral nifedipine, targeting safe levels without over-correction",
"- Avoid diazepam or phenytoin as first-line anticonvulsants",
"- Fluid restriction to avoid pulmonary edema",
"- Stabilize the mother first, then deliver — delivery is the definitive treatment, mode depending on obstetric factors and cervical status",
"- Monitor closely for progression to DIC, pulmonary edema, or cerebral hemorrhage; manage in a high-dependency/ICU setting",
]),
]))

# ---------- CASE 21 ----------
cases.append((21, "Placental Abruption with DIC",
"30-year-old multigravida at 36 weeks gestation with severe abdominal pain, vaginal bleeding, and absent fetal movements since morning. Chronic hypertension for 5 years with poor medication compliance. Anxious, restless, severe pallor, pulse 124, BP 164/112. Uterus tense, woody hard, and tender; fetal parts difficult to palpate; FHS absent. Hb 7.8 g/dL, platelets 72,000/mm3, PT/INR prolonged.",
[
("How will you manage this patient?",
[
"This is placental abruption (likely concealed/mixed, superimposed on poorly controlled chronic hypertension) with intrauterine fetal death and disseminated intravascular coagulation.",
"- Immediate resuscitation: two wide-bore IV lines, crystalloids, cross-matched packed red cell transfusion",
"- Correct coagulopathy with fresh frozen plasma, cryoprecipitate, and platelets as guided by PT/INR, fibrinogen, and platelet count",
"- Foley catheter to monitor urine output closely (risk of acute kidney injury)",
"- Since the fetus is dead, vaginal delivery is preferred once the mother is stabilized — artificial rupture of membranes with oxytocin augmentation if needed",
"- Avoid cesarean section unless a maternal indication arises, since operating on uncorrected coagulopathy risks catastrophic hemorrhage",
"- Watch closely for atonic postpartum hemorrhage after delivery (Couvelaire uterus)",
"- Cautious antihypertensive control; ICU-level monitoring throughout",
]),
]),
("Enumerate causes of DIC in obstetrics.", None))
# fix case 21 tuple structure below manually

cases[-1] = (21, "Placental Abruption with DIC",
"30-year-old multigravida at 36 weeks gestation with severe abdominal pain, vaginal bleeding, and absent fetal movements since morning. Chronic hypertension for 5 years with poor medication compliance. Anxious, restless, severe pallor, pulse 124, BP 164/112. Uterus tense, woody hard, and tender; fetal parts difficult to palpate; FHS absent. Hb 7.8 g/dL, platelets 72,000/mm3, PT/INR prolonged.",
[
("How will you manage this patient?",
[
"This is placental abruption (likely concealed/mixed, superimposed on poorly controlled chronic hypertension) with intrauterine fetal death and disseminated intravascular coagulation.",
"- Immediate resuscitation: two wide-bore IV lines, crystalloids, cross-matched packed red cell transfusion",
"- Correct coagulopathy with fresh frozen plasma, cryoprecipitate, and platelets as guided by PT/INR, fibrinogen, and platelet count",
"- Foley catheter to monitor urine output closely (risk of acute kidney injury)",
"- Since the fetus is dead, vaginal delivery is preferred once the mother is stabilized — artificial rupture of membranes with oxytocin augmentation if needed",
"- Avoid cesarean section unless a maternal indication arises, since operating on uncorrected coagulopathy risks catastrophic hemorrhage",
"- Watch closely for atonic postpartum hemorrhage after delivery (Couvelaire uterus)",
"- Cautious antihypertensive control; ICU-level monitoring throughout",
]),
("Enumerate causes of DIC in obstetrics.",
[
"- Placental abruption",
"- Amniotic fluid embolism",
"- Severe pre-eclampsia / eclampsia / HELLP syndrome",
"- Retained dead fetus (missed intrauterine fetal death)",
"- Septic abortion / sepsis / chorioamnionitis",
"- Massive postpartum hemorrhage",
"- Acute fatty liver of pregnancy",
"- Molar pregnancy",
"- Retained products of conception",
]),
])

# ---------- CASE 22 ----------
cases.append((22, "Umbilical Cord Prolapse",
"26-year-old G2P1L1 at 39 weeks gestation with sudden leakage of liquor followed by a sensation of something protruding per vaginum, and decreased fetal movements for 1 hour. Pulse 92, BP 110/70, uterus term size, longitudinal lie, cephalic presentation, FHR 90/min. Per vaginal exam: pulsating loop of umbilical cord felt below the presenting part. CTG: prolonged fetal bradycardia.",
[
("What is the diagnosis?",
["Umbilical cord prolapse, with fetal bradycardia due to cord compression, occurring after rupture of membranes."]),
("What are the risk factors?",
[
"- Malpresentation (breech, transverse lie)",
"- Polyhydramnios",
"- Prematurity",
"- Multiparity",
"- Multiple gestation",
"- Long umbilical cord",
"- Unengaged presenting part",
"- Premature rupture of membranes, especially with polyhydramnios or artificial rupture with a high presenting part",
"- External cephalic version",
]),
("What immediate measures should be taken?",
[
"- Call for help urgently",
"- Avoid handling or pushing back the exposed cord (minimizes vasospasm)",
"- Manually elevate the presenting part off the cord — keep the examining hand in the vagina",
"- Position the patient in knee-chest position, exaggerated Sim's (left lateral), or Trendelenburg position",
"- Consider filling the bladder with 500-700 mL of saline to elevate the presenting part if transfer is needed",
"- Give tocolytics (e.g., terbutaline) to reduce contractions if appropriate",
"- Continuous fetal monitoring and maternal oxygen",
]),
("What is the definitive management?",
[
"- Immediate delivery is required",
"- Category 1 emergency cesarean section is standard if vaginal delivery is not imminent",
"- If the cervix is fully dilated and vaginal delivery is safe and imminent (e.g., multiparous with a low presenting part), expedite vaginal delivery with forceps or vacuum",
"- Continue manual elevation of the presenting part until the baby is delivered",
]),
]))

# ---------- CASE 23 ----------
cases.append((23, "Pregestational Type 2 Diabetes with Poor Glycemic Control",
"36-year-old G3P1A1 woman at 12 weeks gestation, known type 2 diabetic for 8 years on oral hypoglycemic agents before conception, unplanned pregnancy with no preconception counselling. Previous cesarean for fetal distress, chronic hypertension for 3 years. Pulse 82, BP 138/90, BMI 31, no pedal edema, HbA1c at booking 8.9%.",
[
("What are the key risks and how should this pregnancy be managed?",
[
"Risks: The high periconceptional HbA1c (8.9%, well above the target of less than 6.5-7% ideally before conception) raises the risk of major congenital malformations (cardiac defects, neural tube defects), first-trimester miscarriage, macrosomia, polyhydramnios, superimposed pre-eclampsia (higher risk with coexisting chronic hypertension), stillbirth, shoulder dystocia, and neonatal hypoglycemia.",
"Management:",
"- Early detailed anomaly scan and fetal echocardiography, given the elevated first-trimester HbA1c",
"- Switch oral hypoglycemic agents to insulin for tight glycemic control (metformin may be continued as an adjunct per some protocols)",
"- Start high-dose folic acid (5 mg) immediately",
"- Low-dose aspirin from 12 weeks for pre-eclampsia prophylaxis, given chronic hypertension plus diabetes",
"- Review antihypertensives — stop ACE inhibitors/ARBs if used, switch to pregnancy-safe agents (labetalol, nifedipine, methyldopa)",
"- Serial fetal growth scans through the pregnancy",
"- Plan delivery around 37-39 weeks, likely elective repeat cesarean given the previous cesarean and combined risk factors",
]),
]))

# ---------- CASE 24 ----------
cases.append((24, "HELLP Syndrome",
"29-year-old primigravida at 34 weeks gestation with severe epigastric pain, nausea, and vomiting. BP 160/110, tender right upper abdomen. Hb 9 g/dL, platelets 70,000/mm3, AST/ALT markedly elevated, LDH elevated.",
[
("What is the diagnosis and how should this patient be managed?",
[
"Diagnosis: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) — a severe variant of pre-eclampsia.",
"Management:",
"- Admit and stabilize; control BP with labetalol, hydralazine, or nifedipine",
"- Magnesium sulfate for seizure prophylaxis, given the severe features",
"- Corticosteroids (betamethasone) for fetal lung maturity, given the gestation of 34 weeks",
"- Serial monitoring of platelets, liver function tests, renal function, and coagulation profile (risk of progression to DIC)",
"- Delivery is the definitive treatment — expedite once the mother is stabilized; mode of delivery depends on obstetric factors",
"- Watch for complications: hepatic hematoma or rupture (RUQ pain, may need imaging), DIC, acute kidney injury, placental abruption, pulmonary edema",
"- Platelet transfusion if count is less than 20,000/mm3, or less than 50,000/mm3 before cesarean section",
"- HELLP syndrome can worsen for 48-72 hours postpartum before resolving — continue close monitoring",
]),
]))

# ---------- CASE 25 ----------
cases.append((25, "Acute Pulmonary Edema in Severe Pre-eclampsia",
"31-year-old woman at 34 weeks gestation develops sudden breathlessness. BP 180/120, bilateral basal crepitations. Oxygen saturation 88%.",
[
("What is the diagnosis and how should this patient be managed?",
[
"Diagnosis: Acute pulmonary edema, most likely secondary to severe pre-eclampsia (BP 180/120 with bilateral basal crepitations and hypoxia).",
"Management:",
"- Sit the patient upright, give high-flow oxygen (target saturation above 94-95%)",
"- IV antihypertensives (labetalol or hydralazine) to urgently control severe blood pressure",
"- IV furosemide (diuretic) to relieve pulmonary edema, used cautiously in pregnancy",
"- Restrict IV fluids — fluid overload is a common cause/exacerbant of pulmonary edema in severe pre-eclampsia",
"- Magnesium sulfate for seizure prophylaxis given severe pre-eclampsia features",
"- Continuous pulse oximetry, cardiac monitoring, and Foley catheter for strict input-output monitoring",
"- Once stabilized, plan for delivery — the definitive treatment of pre-eclampsia",
"- Consider echocardiography to exclude peripartum cardiomyopathy as a differential; involve ICU/anesthesia teams",
]),
]))

# ---------- CASE 26 ----------
cases.append((26, "Major Placenta Previa with Suspected Accreta Spectrum",
"33-year-old G3P2L2 at 35+4 weeks gestation with sudden onset painless bright red vaginal bleeding for 2 hours, no pain or trauma. Two previous cesarean sections, last one 3 years back. No hypertension. Fetal movements present. Pulse 106, BP 100/68. Uterus relaxed, non-tender, presenting part high and floating, FHS 138/min regular. No digital vaginal exam performed. USG: placenta completely covering the internal os, multiple placental lacunae, loss of the retroplacental clear zone.",
[
("What are the differential diagnoses of antepartum hemorrhage?",
[
"- Placenta previa",
"- Placental abruption",
"- Vasa previa",
"- Marginal sinus bleed",
"- Local causes: cervical polyp, cervicitis, cervical cancer, vaginal/cervical trauma",
"- Uterine rupture (in labour)",
"- Bloody 'show' of labour (a benign cause)",
]),
("How will you evaluate and manage this patient?",
[
"No digital vaginal examination was performed — correct, as this can provoke massive hemorrhage in placenta previa.",
"- Confirm with transvaginal ultrasound (already done, confirming complete previa)",
"- The presence of placental lacunae and loss of the retroplacental clear zone, together with two previous cesarean sections, raises strong suspicion of placenta accreta spectrum — further imaging (MRI where available) and multidisciplinary planning are needed",
"- Admit for observation given active bleeding; send CBC and group & cross-match (arrange blood products given the accreta risk)",
"- IV access; corticosteroids for fetal lung maturity, given the gestation is under 36 weeks",
"- If bleeding settles, manage expectantly with close monitoring; if bleeding is heavy or uncontrolled, or there is fetal distress, proceed to emergency cesarean section",
"- Definitive delivery: planned elective cesarean around 36-37 weeks at a tertiary center with blood bank and interventional radiology backup, given the risk of massive hemorrhage and possible need for cesarean hysterectomy if accreta is confirmed",
"- Anti-D immunoglobulin if Rh-negative",
]),
]))

# ---------- CASE 27 ----------
cases.append((27, "Obstructed Labour with Impending Uterine Rupture",
"20-year-old primigravida referred after prolonged labour of nearly 20 hours, with severe abdominal pain, inability to pass urine, and exhaustion. No antenatal records. Dehydrated, pulse 128, BP 90/60, temperature 38.5C. Uterus hypertonic with a visible pathological retraction ring. Fetal head deeply impacted, FHS absent. Cervix fully dilated, membranes absent, caput +++, moulding +++, vertex at 0 station.",
[
("Discuss causes and complications of obstructed labour.",
[
"Causes:",
"- Fetal: malposition (occipito-posterior), malpresentation (brow, face, shoulder/transverse lie), macrosomia, fetal anomalies (hydrocephalus, conjoined twins)",
"- Maternal/pelvic: cephalopelvic disproportion (contracted or rachitic pelvis, previous pelvic fracture), pelvic tumors (fibroid, ovarian mass) obstructing the birth canal, cervical stenosis/scarring",
"- Soft tissue: vaginal septum, scarring from previous surgery",
"Complications:",
"- Maternal: uterine rupture (the pathological retraction ring/Bandl's ring seen here is a danger sign of impending rupture), postpartum hemorrhage, obstetric fistula (vesicovaginal/rectovaginal from prolonged pressure necrosis), sepsis/puerperal infection, maternal exhaustion/shock, and death",
"- Fetal: fetal distress/hypoxia, intrauterine death (already present here), birth asphyxia, caput succedaneum/cephalhematoma, skull fracture",
]),
("Outline detailed management of this patient.",
[
"- Resuscitate first: IV fluids for dehydration and shock, catheterize the bladder to relieve retention and monitor output, broad-spectrum IV antibiotics for likely sepsis/chorioamnionitis (fever 38.5C), correct electrolytes",
"- Critically assess for uterine rupture — the pathological retraction ring is a red-flag danger sign",
"- If rupture is suspected, proceed straight to emergency laparotomy — do NOT attempt vaginal delivery",
"- If no signs of rupture, the cervix is fully dilated, and the vertex is at station 0 with a dead fetus, a destructive vaginal delivery (craniotomy) or instrumental delivery may be considered per protocol; otherwise proceed to laparotomy",
"- Postpartum: manage risk of atonic postpartum hemorrhage, continue antibiotics, monitor closely for fistula formation over subsequent weeks",
"- Offer bereavement counselling and psychological support given the perinatal loss",
]),
]))

# ---------- CASE 28 ----------
cases.append((28, "Severe Anemia in Pregnancy at Term",
"26-year-old primigravida at 38 weeks gestation, referred with Hb 6.2 g/dL, asymptomatic. Pallor present, hemodynamically stable.",
[
("What are the indications for blood transfusion in pregnancy?",
[
"- Hb less than 7 g/dL (severe anemia), especially near term or in labour",
"- Symptomatic anemia at any Hb level (dyspnea, tachycardia, signs of cardiac failure)",
"- Active or anticipated significant blood loss (hemorrhage, bleeding placenta previa)",
"- Pre-operative correction of Hb below 7 g/dL before cesarean section",
"- Failure of, or insufficient time for, iron therapy to correct anemia before delivery",
]),
("How will you manage this patient near term?",
[
"At 38 weeks with Hb 6.2 g/dL, there is insufficient time remaining for oral or IV iron alone to adequately correct the anemia before delivery.",
"- Transfuse packed red cells to correct the anemia and reduce the risk of decompensation and poor tolerance of blood loss at delivery",
"- Supplement additionally with IV iron to replenish stores",
"- Plan delivery at a center with blood bank facilities",
"- Actively manage the third stage of labour to minimize blood loss",
"- Induction or cesarean section only if obstetrically indicated, not for anemia alone",
"- Keep cross-matched blood ready at the time of delivery",
]),
]))

# ---------- CASE 29 ----------
cases.append((29, "Severe Fetal Growth Restriction",
"22-year-old primigravida at 33 weeks gestation, referred for reduced symphysiofundal height, no leaking/bleeding/pain, fetal movements normal. Pulse 86, BP 150/96, mild pedal edema. Fundal height 29 weeks (reduced for dates), liquor clinically reduced, FHS 142/min. USG: estimated fetal weight below 3rd percentile, oligohydramnios, absent end-diastolic flow on umbilical artery Doppler, abnormal MCA Doppler.",
[
("How will you differentiate constitutionally small fetus from fetal growth restriction?",
[
"Constitutionally small (SGA): EFW below the 10th percentile but with normal growth velocity on serial scans, normal umbilical artery Doppler (normal end-diastolic flow), normal amniotic fluid volume, normal cerebroplacental ratio, symmetric proportionate growth — often reflects small but healthy parents/ethnicity, with low risk of adverse perinatal outcome.",
"Fetal growth restriction (pathological): EFW below the 10th percentile (often below the 3rd, as in this case) AND Doppler abnormality — absent or reversed end-diastolic flow in the umbilical artery (indicating placental insufficiency), abnormal 'brain-sparing' MCA Doppler — plus oligohydramnios, static or crossing centiles on serial scans, often asymmetric (head-sparing) growth, and association with maternal disease (this patient's BP 150/96 with edema suggests superimposed pre-eclampsia).",
"This patient's combination — EFW below 3rd percentile, oligohydramnios, absent end-diastolic flow, and abnormal MCA Doppler — indicates severe, placental-origin fetal growth restriction, a high-risk finding.",
]),
("Discuss surveillance and timing of delivery in this patient.",
[
"- Serial growth scans every 2 weeks",
"- Doppler studies (umbilical artery, MCA, ductus venosus) weekly to twice-weekly depending on severity",
"- CTG and biophysical profile monitoring",
"- With absent end-diastolic flow at 33 weeks: give corticosteroids now for fetal lung maturity and plan delivery by around 34 weeks",
"- Deliver sooner if the ductus venosus becomes abnormal (reversed a-wave), if reversed end-diastolic flow develops, or if CTG/biophysical profile deteriorates",
"- Consider magnesium sulfate for fetal neuroprotection given the anticipated preterm delivery",
"- Deliver by planned cesarean section, as labour is poorly tolerated with abnormal Dopplers, at a center with NICU facilities",
"- Concurrently manage the likely superimposed pre-eclampsia (BP control, monitoring for progression)",
]),
]))

# ---------- CASE 30 ----------
cases.append((30, "Rheumatic Mitral Stenosis Decompensating in Pregnancy",
"24-year-old primigravida at 30 weeks gestation with progressive shortness of breath for the last 2 weeks, comfortable at rest but breathless on climbing a flight of stairs, occasional palpitations. Pulse 108 regular, BP 110/70, respiratory rate 24, mild bilateral pedal edema. JVP not elevated. CVS exam: mid-diastolic murmur best heard at the apex.",
[
("What is the diagnosis and how should this patient be managed?",
[
"Diagnosis: A mid-diastolic murmur best heard at the apex is the classic finding of mitral stenosis, most commonly of rheumatic origin. The progressive exertional dyspnea and palpitations represent cardiac decompensation under the increased hemodynamic load of pregnancy (functional worsening, moving toward NYHA Class III — symptomatic on less-than-ordinary activity).",
"Management:",
"- Multidisciplinary care involving cardiology, obstetrics, and anesthesia",
"- Bed rest and salt restriction",
"- Diuretics (furosemide) to relieve congestion",
"- Cardioselective beta-blocker to slow the heart rate and prolong diastolic filling time, which helps in mitral stenosis",
"- Anticoagulation (low molecular weight heparin) if atrial fibrillation is present or the left atrium is significantly enlarged",
"- Echocardiography to grade the severity of stenosis and estimate pulmonary artery pressure",
"- Treat any precipitating factor (anemia, infection, arrhythmia)",
"- Balloon mitral valvotomy if severe and refractory to medical therapy (can be performed safely, ideally in the second trimester)",
"- Delivery: vaginal delivery with good analgesia and an assisted, shortened second stage (forceps/vacuum) is generally preferred to reduce cardiac strain; cesarean section reserved for obstetric indications or severe decompensation",
"- Avoid fluid overload around the time of delivery; monitor closely in the immediate postpartum period for pulmonary edema due to the autotransfusion effect after delivery",
]),
]))

# =========================================================================
# BUILD DOCUMENT
# =========================================================================

for c in cases:
    number, title, vignette, qa_list = c
    add_case(number, title, vignette, qa_list)

doc.save("/tmp/workspace/obgyn_cases/OBGYN_Case_Discussions_30_Cases.docx")
print("Document created successfully.")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/obgyn_cases/build_doc.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/obgyn_cases/build_doc.py'