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pres.title = "Hypertensive Disorders of Pregnancy - Pre-eclampsia";
pres.author = "Medical Education";

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// ==================== SLIDES ====================

// SLIDE 1: Title
titleSlide(pres,
  "Hypertensive Disorders of Pregnancy",
  "Pre-eclampsia: Definitions • Etiopathology • Prediction • Prevention • Investigations • Management"
);

// SLIDE 2: Overview / Epidemiology
contentSlide(pres, "Overview & Epidemiology", [
  { type: "heading", text: "Burden of Disease" },
  { text: "Affects 5–7% of births; up to 15% of women experience hypertensive disorders of pregnancy (HDP)" },
  { text: "Leading cause of maternal and perinatal morbidity and mortality worldwide" },
  { text: "Contributes to 7% of maternal deaths (stroke, pulmonary edema, hepatic rupture)" },
  { text: "Accounts for ~20% of perinatal deaths" },
  { type: "heading", text: "Spectrum of Hypertensive Disorders in Pregnancy" },
  { text: "Gestational hypertension (PIH)" },
  { text: "Pre-eclampsia / Eclampsia" },
  { text: "HELLP syndrome" },
  { text: "Chronic hypertension" },
  { text: "Chronic hypertension with superimposed pre-eclampsia" },
], "Source: Creasy & Resnik's Maternal-Fetal Medicine, 8e; Morgan & Mikhail's Clinical Anesthesiology, 7e");

// SLIDE 3: Section divider - Definitions
sectionSlide(pres, "01", "Definitions & Classification", "Diagnostic Criteria & Categories");

// SLIDE 4: Definitions
contentSlide(pres, "Definitions: Hypertension in Pregnancy", [
  { type: "heading", text: "Gestational Hypertension (PIH)" },
  { text: "SBP ≥140 mmHg OR DBP ≥90 mmHg on two occasions ≥4 hours apart" },
  { text: "After 20 weeks of gestation in a previously normotensive woman" },
  { text: "No proteinuria or end-organ damage" },
  { type: "heading", text: "Pre-eclampsia" },
  { text: "Hypertension (as above) PLUS proteinuria (>300 mg/day or protein:creatinine >0.3)" },
  { text: "OR, even without proteinuria: new-onset thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, new-onset headache unresponsive to medication, visual symptoms" },
  { type: "heading", text: "Eclampsia" },
  { text: "New-onset grand mal seizures in a woman with pre-eclampsia — not attributable to other causes" },
], "ACOG Task Force on Hypertension in Pregnancy (2013); Creasy & Resnik, 8e");

// SLIDE 5: Severe Features & HELLP
contentSlide(pres, "Pre-eclampsia with Severe Features & HELLP", [
  { type: "heading", text: "Severe Features (any ONE qualifies)" },
  { text: "SBP ≥160 mmHg or DBP ≥110 mmHg (on two occasions ≥4 h apart while on antihypertensive therapy)" },
  { text: "Thrombocytopenia: platelet count <100,000/μL" },
  { text: "Renal insufficiency: serum creatinine >1.1 mg/dL or doubling without other renal disease" },
  { text: "Impaired liver function: elevated transaminases (2× normal), severe RUQ / epigastric pain unresponsive to medication" },
  { text: "Pulmonary edema" },
  { text: "New-onset headache unresponsive to medication; visual disturbances" },
  { type: "heading", text: "HELLP Syndrome" },
  { text: "Hemolysis (microangiopathic hemolysis, LDH >600 IU/L)" },
  { text: "Elevated Liver enzymes (AST/ALT ≥ 2× upper limit of normal)" },
  { text: "Low Platelets (< 100,000/μL)" },
], "ACOG (2013); Brenner & Rector's The Kidney, 10e");

// SLIDE 6: Section divider - Etiopathology
sectionSlide(pres, "02", "Etiopathology", "Mechanisms & Pathophysiology");

// SLIDE 7: Role of Placenta
contentSlide(pres, "Etiopathology: Role of the Placenta", [
  { type: "heading", text: "Central Role of the Placenta" },
  { text: "Pre-eclampsia occurs ONLY in the presence of a placenta (including hydatidiform mole without a fetus)" },
  { text: "Almost always remits after placental delivery" },
  { text: "In ectopic pregnancy with pre-eclampsia — symptoms persisted until placenta removed, not just fetus" },
  { type: "heading", text: "Evidence for Placental Ischemia" },
  { text: "Pathologic findings: acute atherosis, fibrin deposition, intimal thickening, necrosis, endothelial damage, spiral artery infarcts" },
  { text: "Abnormal uterine artery Doppler (decreased uteroplacental perfusion) appears BEFORE clinical onset" },
  { text: "Incidence 2–4× higher at high altitude (hypoxia as contributing factor)" },
  { text: "Global gene expression profiles similar in hypoxia-treated placentae, high-altitude placentae, and pre-eclamptic placentae" },
], "Brenner & Rector's The Kidney, 10e, pp. 2148–2154");

// SLIDE 8: Abnormal Placental Vascular Remodeling
contentSlide(pres, "Abnormal Placental Vascular Remodeling", [
  { type: "heading", text: "Normal Placentation" },
  { text: "Extravillous cytotrophoblasts invade uterine spiral arteries of decidua AND myometrium" },
  { text: "Replace endothelial layer → transform narrow resistance vessels into wide, flaccid, high-capacitance vessels" },
  { text: "This transformation enables the increased uterine blood flow needed to sustain the fetus" },
  { type: "heading", text: "In Pre-eclampsia (Defective Remodeling)" },
  { text: "Cytotrophoblast invasion limited to superficial decidua ONLY" },
  { text: "Myometrial segments remain narrow and undilated → reduced uteroplacental perfusion" },
  { text: "Cytotrophoblasts fail to switch from epithelial to endothelial adhesion phenotype (pseudovasculogenesis defect)" },
  { text: "HIF-1 (Hypoxia Inducible Factor-1) activity increased → maintains trophoblasts in hypoxic, epithelial state" },
], "Brenner & Rector's The Kidney, 10e; Fisher et al., placental invasion studies");

// SLIDE 9: Angiogenic Imbalance
contentSlide(pres, "Angiogenic Imbalance in Pre-eclampsia", [
  { type: "heading", text: "Anti-angiogenic Factors (Elevated)" },
  { text: "sFlt-1 (soluble FMS-like tyrosine kinase-1): binds and sequesters VEGF and PlGF → prevents receptor activation" },
  { text: "sEng (soluble endoglin): anti-TGF-β1, impairs eNOS-dependent vasodilation" },
  { text: "Both rise 5–8 weeks BEFORE clinical onset of pre-eclampsia" },
  { type: "heading", text: "Pro-angiogenic Factors (Decreased)" },
  { text: "PlGF (Placental Growth Factor): markedly reduced" },
  { text: "VEGF: reduced by sFlt-1 sequestration" },
  { type: "heading", text: "Downstream Effects" },
  { text: "Systemic endothelial dysfunction → hypertension, proteinuria, end-organ damage" },
  { text: "Elevated TXA2 (thromboxane A2): potent vasoconstrictor + platelet aggregation promoter" },
  { text: "Decreased PGI2 (prostacyclin): normally a vasodilator + platelet aggregation inhibitor" },
  { text: "Decreased nitric oxide (eNOS) production → vasoconstriction" },
], "Brenner & Rector's The Kidney, 10e; Morgan & Mikhail, 7e");

// SLIDE 10: Risk Factors
contentSlide(pres, "Risk Factors for Pre-eclampsia", [
  { type: "heading", text: "High-Risk (Relative Risk >2)" },
  { text: "Nulliparity — most common single risk factor" },
  { text: "Prior pre-eclampsia (RR 7–10x for recurrence)" },
  { text: "Multifetal gestation (10–20% twins; 25–60% triplets; up to 90% quadruplets)" },
  { text: "Chronic hypertension, renal disease, diabetes, autoimmune conditions (SLE, antiphospholipid syndrome)" },
  { text: "Obesity (BMI ≥35 kg/m²)" },
  { text: "Hydatidiform mole" },
  { type: "heading", text: "Moderate-Risk Factors" },
  { text: "Age ≥40 years; family history of pre-eclampsia" },
  { text: "Interpregnancy interval >10 years" },
  { text: "Thrombophilias (Factor V Leiden, prothrombin gene mutation)" },
  { text: "Assisted reproductive technology (ART)" },
], "Creasy & Resnik's Maternal-Fetal Medicine, 8e; ACOG Practice Bulletin");

// SLIDE 11: Multisystem Pathophysiology
twoColSlide(pres,
  "Multisystem Pathophysiological Effects",
  "Maternal Organ Systems Affected",
  [
    { text: "Neurological: headache, visual disturbances, hyperexcitability, seizures, intracranial hemorrhage, cerebral edema" },
    { text: "Pulmonary: upper airway edema, pulmonary edema" },
    { text: "Cardiovascular: decreased intravascular volume, increased arteriolar resistance, hypertension, heart failure" },
    { text: "Hepatic: elevated enzymes, RUQ pain, hematoma, rupture" },
    { text: "Renal: proteinuria, Na retention, decreased GFR, acute kidney injury" },
    { text: "Hematological: coagulopathy, thrombocytopenia, microangiopathic hemolysis, prolonged PTT" },
  ],
  "Hemodynamic Profile",
  [
    { text: "Most patients: low-normal cardiac filling pressures + increased systemic vascular resistance" },
    { text: "Cardiac output: may be reduced, normal, or increased — widely variable" },
    { text: "Intravascular volume depletion despite edema (third spacing)" },
    { text: "Glomeruloendotheliosis (pathognomonic renal lesion): swollen endothelial cells obliterate glomerular capillary lumens" },
    { text: "Increased endothelin-1 → potent vasoconstriction + platelet activation" },
    { text: "Long-term: 50% develop hypertension later in life; 5x increased ESRD risk" },
  ],
  "Source: Morgan & Mikhail, 7e; Brenner & Rector, 10e"
);

// SLIDE 12: Section divider - Predictive Factors
sectionSlide(pres, "03", "Predictive Factors", "Screening & Early Detection");

// SLIDE 13: Clinical & Biochemical Predictors
contentSlide(pres, "Predictive Factors: Clinical & Biochemical", [
  { type: "heading", text: "First-Trimester Screening (Combined Model — FMF)" },
  { text: "Mean arterial pressure (MAP): elevated MAP at 11–14 weeks" },
  { text: "Uterine artery Doppler: raised pulsatility index (PI) — impaired placentation" },
  { text: "Placental Growth Factor (PlGF): low levels predict early-onset disease" },
  { text: "Pregnancy-associated plasma protein-A (PAPP-A): low levels associated with pre-eclampsia" },
  { text: "Combined screen (MAP + UtA Doppler + PlGF + PAPP-A): detection rate ~75–90% for early pre-eclampsia at 5% FPR" },
  { type: "heading", text: "Second-Trimester Markers" },
  { text: "Uterine artery Doppler with notching (sensitivity 65–85%); wide regional variability in use" },
  { text: "Placental Protein-13 (PP-13): low levels in first trimester — better for early-onset disease" },
  { text: "sFlt-1 / PlGF ratio: elevated ratio predicts onset 5–8 weeks in advance; >38 suggests short-term onset" },
  { text: "sEng levels: rise significantly before clinical pre-eclampsia" },
], "Brenner & Rector's The Kidney, 10e; Creasy & Resnik, 8e");

// SLIDE 14: Predictive Factors Table
tableSlide(pres,
  "Predictive Biomarkers: Summary",
  ["Biomarker", "Timing", "Significance"],
  [
    ["PlGF (Placental Growth Factor)", "1st & 2nd trimester", "Low → pre-eclampsia risk; combined screen"],
    ["sFlt-1 / PlGF Ratio", "5–8 wks pre-onset", "Ratio >38 predicts short-term onset"],
    ["PAPP-A", "11–14 weeks", "Low PAPP-A → increased PE risk"],
    ["PP-13 (Placental Protein-13)", "1st trimester", "Low → high risk; mainly early-onset PE"],
    ["Uterine Artery Doppler PI", "11–14 wks & 20–24 wks", "High PI / notching → defective remodeling"],
    ["Mean Arterial Pressure", "11–14 weeks", "Elevated → risk stratification"],
    ["sEng (Soluble Endoglin)", "Weeks before onset", "Anti-angiogenic; impairs NO signaling"],
  ],
  "Source: Brenner & Rector's The Kidney, 10e; Creasy & Resnik, 8e"
);

// SLIDE 15: Section divider - Prevention
sectionSlide(pres, "04", "Prevention of Pre-eclampsia", "Evidence-Based Strategies");

// SLIDE 16: Prevention Strategies
contentSlide(pres, "Prevention of Pre-eclampsia", [
  { type: "heading", text: "Low-Dose Aspirin (MOST EVIDENCE-BASED)" },
  { text: "Mechanism: inhibits TXA2 > PGI2 → restores vasoprotective balance" },
  { text: "Dose: 81–150 mg/day (ACOG recommends 81 mg; NICE / FMF: 150 mg for high-risk women)" },
  { text: "Initiation: ideally at 11–14 weeks, no later than 16 weeks — before placental ischemia establishes" },
  { text: "Continue until delivery" },
  { text: "High-risk: ≥1 high-risk factor (prior PE, multifetal, chronic HTN, diabetes, renal disease)" },
  { text: "Moderate risk: ≥2 moderate risk factors → prescribe aspirin" },
  { type: "heading", text: "Calcium Supplementation" },
  { text: "1–2 g/day elemental calcium in populations with low dietary calcium intake" },
  { text: "Reduces risk of pre-eclampsia by ~50% in calcium-deficient populations (Cochrane review)" },
  { type: "heading", text: "Other Measures (Limited Evidence)" },
  { text: "Vitamin C & E: NOT recommended (large RCTs showed no benefit)" },
  { text: "Heparin: may benefit women with thrombophilia (individualized decision)" },
  { text: "Optimal gestational weight management, treatment of pre-existing hypertension" },
], "ACOG Practice Bulletin 222; Cochrane Reviews; Creasy & Resnik, 8e");

// SLIDE 17: Aspirin Prevention - Detail
contentSlide(pres, "Low-Dose Aspirin: The Evidence", [
  { type: "heading", text: "ASPRE Trial (2017) — Key RCT" },
  { text: "N = 1776 high-risk women (FMF combined screen): aspirin 150 mg vs placebo from 11–14 weeks" },
  { text: "Result: 62% reduction in pre-term pre-eclampsia (<37 weeks) — NNT ~16" },
  { text: "No significant reduction in term pre-eclampsia" },
  { type: "heading", text: "Mechanism & Rationale" },
  { text: "Low-dose aspirin preferentially inhibits platelet TXA2 production" },
  { text: "Preserves endothelial prostacyclin (PGI2) → net vasodilatory, anti-aggregation effect" },
  { text: "Bedtime dosing may be more effective (circadian variation in thromboxane levels)" },
  { type: "heading", text: "Multifetal Gestations (Special Consideration)" },
  { text: "ACOG: Prescribe aspirin 81 mg/day from 12 weeks → delivery for all women with multifetal gestation" },
  { text: "NICE (UK): Only if ≥2 additional risk factors (age >40, BMI >35, interval >10 yr)" },
  { text: "Recent meta-analysis: aspirin may slightly reduce mild pre-eclampsia in twins; no impact on severe PE or SGA" },
], "Rolnik et al. ASPRE Trial, NEJM 2017; ACOG; Creasy & Resnik, 8e");

// SLIDE 18: Section divider - Investigations
sectionSlide(pres, "05", "Investigations", "Laboratory, Imaging & Monitoring");

// SLIDE 19: Investigations
contentSlide(pres, "Investigations in Pre-eclampsia", [
  { type: "heading", text: "Baseline & Confirmatory Tests" },
  { text: "Blood pressure: two readings ≥4 hours apart (or 15 min if severe features)" },
  { text: "Urinalysis: spot urine protein:creatinine ratio (PCR ≥0.3) or 24-hour urine protein (≥300 mg)" },
  { text: "Full blood count (FBC): platelets, hemoglobin (look for thrombocytopenia, hemolysis)" },
  { type: "heading", text: "Biochemical Panel" },
  { text: "LFTs: ALT, AST (elevated ≥2× ULN in HELLP)" },
  { text: "Renal function: serum creatinine, urea (Cr >1.1 mg/dL significant)" },
  { text: "LDH: elevated in HELLP (>600 IU/L), indicates hemolysis" },
  { text: "Serum uric acid: elevated (not diagnostic but useful marker)" },
  { text: "Coagulation screen: PT, APTT, fibrinogen (especially if platelets <100,000/μL)" },
  { type: "heading", text: "Biomarkers for Prediction/Diagnosis" },
  { text: "sFlt-1 / PlGF ratio: ratio >38 predicts onset within 4 weeks (high NPV >99%)" },
  { text: "24-hour urine protein or albumin:creatinine ratio" },
], "Creasy & Resnik, 8e; Brenner & Rector, 10e");

// SLIDE 20: Investigations - Fetal & Imaging
contentSlide(pres, "Investigations: Fetal Assessment & Imaging", [
  { type: "heading", text: "Fetal Monitoring" },
  { text: "Cardiotocography (CTG): non-stress test (NST) for fetal wellbeing" },
  { text: "Biophysical profile (BPP): assessment of fetal movements, tone, breathing, amniotic fluid" },
  { text: "Serial growth ultrasound: detect intrauterine growth restriction (IUGR) — common complication" },
  { type: "heading", text: "Doppler Studies" },
  { text: "Uterine artery Doppler: high PI, notching → defective spiral artery remodeling" },
  { text: "Umbilical artery Doppler: absent or reversed end-diastolic flow → severe placental insufficiency" },
  { text: "Middle cerebral artery (MCA) Doppler: brain-sparing effect in IUGR" },
  { type: "heading", text: "Maternal Imaging (Severe Cases)" },
  { text: "CT/MRI brain: if eclampsia or focal neurological signs (rule out PRES — posterior reversible encephalopathy syndrome)" },
  { text: "Abdominal ultrasound: hepatic hematoma, subcapsular hemorrhage (severe hepatic involvement)" },
  { text: "Chest X-ray / POCUS: pulmonary edema assessment" },
], "Creasy & Resnik, 8e; Brenner & Rector, 10e");

// SLIDE 21: Section divider - Management
sectionSlide(pres, "06", "Management", "Antihypertensives • Magnesium • Delivery");

// SLIDE 22: Management - General Principles
contentSlide(pres, "Management: General Principles & BP Targets", [
  { type: "heading", text: "Definitive Treatment" },
  { text: "Delivery of fetus and placenta is the ONLY definitive treatment" },
  { text: "Timing balances fetal prematurity risk vs. maternal/fetal morbidity of continued pregnancy" },
  { type: "heading", text: "BP Management Goals" },
  { text: "Antihypertensive therapy NOT initiated unless BP >150/100 mmHg (to avoid acute fetal compromise from aggressive lowering)" },
  { text: "Target: reduce to 140–155 / 90–105 mmHg (avoid normalizing BP acutely)" },
  { text: "Acute treatment threshold: SBP ≥160 or DBP ≥110 mmHg — risk of maternal stroke" },
  { type: "heading", text: "Delivery Timing" },
  { text: "< 24 weeks: perinatal mortality >80%; termination usually recommended" },
  { text: "24–34 weeks: expectant management if maternal/fetal status stable; corticosteroids for lung maturity" },
  { text: "34–37 weeks: consider expediting; RCTs show expectant approach reduces neonatal RDS" },
  { text: "> 37 weeks: delivery indicated" },
  { text: "Immediate delivery for: non-reassuring CTG, abruption, thrombocytopenia, worsening renal/liver function, unrelenting headache/visual changes" },
], "Brenner & Rector, 10e; Creasy & Resnik, 8e");

// SLIDE 23: Antihypertensive Drugs
tableSlide(pres,
  "Antihypertensive Drugs in Pregnancy",
  ["Drug", "Route / Dose", "Notes"],
  [
    ["Labetalol (α+β blocker)", "IV 5–10 mg boluses; oral 200–400 mg BD", "First-line IV agent; avoids tachycardia; minimal placental transfer"],
    ["Hydralazine", "IV 5 mg boluses; repeat q20 min", "Direct vasodilator; risk of maternal hypotension — give IV fluid"],
    ["Nifedipine (CCB)", "Oral 10–20 mg IR; 30–60 mg SR", "Oral first-line; beware interaction with Mg sulfate → hypotension"],
    ["Methyldopa", "Oral 250–500 mg BD/TDS", "Safe, well-studied in pregnancy; NOT for acute hypertensive crisis"],
    ["Nicardipine / Clevidipine", "IV infusion (perioperative)", "Short-acting CCB for intraoperative hypertension"],
    ["ACEi / ARBs", "CONTRAINDICATED", "Fetotoxic — renal dysgenesis, oligohydramnios, neonatal death"],
    ["Sodium Nitroprusside", "IV infusion (last resort)", "Risk of fetal cyanide toxicity; brief use only"],
  ],
  "Source: Morgan & Mikhail, 7e; Brenner & Rector, 10e; ACOG"
);

// SLIDE 24: Magnesium Sulfate & Eclampsia
contentSlide(pres, "Magnesium Sulfate: Seizure Prophylaxis & Treatment", [
  { type: "heading", text: "Indications" },
  { text: "Prevention of eclamptic seizures in pre-eclampsia with severe features" },
  { text: "Treatment of eclampsia (acute seizure management)" },
  { text: "Superior to diazepam and phenytoin — proven in Magpie Trial (N>10,000 women, 33 countries)" },
  { text: "Magpie Trial: MgSO4 reduced eclamptic seizures by 50% (0.8% vs 1.9%, p<0.001)" },
  { type: "heading", text: "Dosing Regimen (Pritchard / Modified)" },
  { text: "Loading dose: 4–6 g IV over 20–30 minutes" },
  { text: "Maintenance: 1–2 g/hour IV infusion" },
  { text: "Therapeutic serum level: 4–7 mEq/L (2–3.5 mmol/L)" },
  { type: "heading", text: "Toxicity Monitoring & Antidote" },
  { text: "Monitor: deep tendon reflexes (lost at 7–10 mEq/L), respiratory rate (>12/min), urine output (>25 mL/hr)" },
  { text: "Respiratory arrest at >12 mEq/L; cardiac arrest at >15 mEq/L" },
  { text: "Antidote: Calcium gluconate 1 g IV over 10 minutes (readily at bedside)" },
  { text: "Potentiates neuromuscular blocking agents — reduce NMB doses with nerve stimulator guidance" },
], "Magpie Trial Collaborative Group, Lancet 2002; Morgan & Mikhail, 7e; Brenner & Rector, 10e");

// SLIDE 25: Summary & Long-term Outlook
contentSlide(pres, "Summary & Long-term Implications", [
  { type: "heading", text: "Key Management Summary" },
  { text: "Pre-eclampsia: multisystem disorder driven by defective placental vascular remodeling → endothelial dysfunction" },
  { text: "Delivery is definitive — timing individualized by gestational age and disease severity" },
  { text: "MgSO4 for seizure prevention; antihypertensives to prevent maternal stroke; steroids for fetal lung maturity <34 weeks" },
  { text: "Screen high-risk women early: combined FMF screen + low-dose aspirin from 11–16 weeks" },
  { type: "heading", text: "Long-term Cardiovascular Risk" },
  { text: "50% of women with pre-eclampsia develop hypertension in later life" },
  { text: "2× risk of ischemic heart disease, stroke, cardiomyopathy, cardiovascular mortality" },
  { text: "5× increased risk of end-stage renal disease (ESRD)" },
  { text: "AHA identifies prior hypertension in pregnancy as established CVD risk factor" },
  { text: "Women with prior pre-eclampsia should receive: BP monitoring, lipid screening, lifestyle counseling" },
  { type: "heading", text: "Pregnancy as a Cardiovascular Stress Test" },
  { text: "Abnormal pregnancy outcomes reveal subclinical vascular risk — opportunity for early CVD prevention" },
], "Creasy & Resnik, 8e; Brenner & Rector, 10e; AHA Guidelines");

// Write file
pres.writeFile({ fileName: "/home/daytona/workspace/hypertensive-pregnancy-ppt/Hypertensive_Disorders_Pregnancy.pptx" })
  .then(() => console.log("SUCCESS: PPTX created!"))
  .catch(e => console.error("ERROR:", e));