Twin Pregnancy: MS Obstetrics and Gynaecology Long Case (20 marks)

from pptx import Presentation
from pptx.util import Inches, Pt
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.shapes import MSO_SHAPE
from pptx.oxml.ns import qn
from lxml import etree

A = "/tmp/workspace/twin-pregnancy-ppt/assets/"
NAVY = RGBColor(0x12, 0x2B, 0x4A)
TEAL = RGBColor(0x0F, 0x8B, 0x8D)
CORAL = RGBColor(0xE0, 0x5A, 0x47)
GOLD = RGBColor(0xF2, 0xA9, 0x00)
LIGHT = RGBColor(0xF4, 0xF7, 0xFA)
WHITE = RGBColor(0xFF, 0xFF, 0xFF)
DARK = RGBColor(0x23, 0x2F, 0x3E)
GREY = RGBColor(0x6B, 0x77, 0x85)
PALE_TEAL = RGBColor(0xE1, 0xF2, 0xF2)
PALE_CORAL = RGBColor(0xFB, 0xE7, 0xE3)
FONT = "Calibri"

prs = Presentation()
prs.slide_width = Inches(13.333)
prs.slide_height = Inches(7.5)
BLANK = prs.slide_layouts[6]
state = {"n": 0}


def rect(s, x, y, w, h, fill, line=None, shape=MSO_SHAPE.RECTANGLE):
    r = s.shapes.add_shape(shape, Inches(x), Inches(y), Inches(w), Inches(h))
    r.fill.solid()
    r.fill.fore_color.rgb = fill
    if line is None:
        r.line.fill.background()
    else:
        r.line.color.rgb = line
        r.line.width = Pt(1)
    r.shadow.inherit = False
    return r


def text(s, x, y, w, h, t, size=18, bold=False, color=DARK, align=PP_ALIGN.LEFT,
         anchor=MSO_ANCHOR.TOP, italic=False):
    tb = s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.vertical_anchor = anchor
    tf.margin_left = tf.margin_right = Inches(0.05)
    tf.margin_top = tf.margin_bottom = Inches(0.03)
    p = tf.paragraphs[0]
    p.alignment = align
    r = p.add_run()
    r.text = t
    r.font.size = Pt(size)
    r.font.bold = bold
    r.font.italic = italic
    r.font.name = FONT
    r.font.color.rgb = color
    return tb


def set_bullet(p, char="\u2022", indent=0.22, level_off=0.0, color=None):
    pPr = p._p.get_or_add_pPr()
    pPr.set("marL", str(int(Inches(indent + level_off))))
    pPr.set("indent", str(-int(Inches(indent))))
    for tag in ("a:buNone", "a:buChar", "a:buClr"):
        for e in pPr.findall(qn(tag)):
            pPr.remove(e)
    if color is not None:
        bc = etree.SubElement(pPr, qn("a:buClr"))
        c = etree.SubElement(bc, qn("a:srgbClr"))
        c.set("val", "%02X%02X%02X" % (color[0], color[1], color[2]))
    bu = etree.SubElement(pPr, qn("a:buChar"))
    bu.set("char", char)


def bullets(s, x, y, w, h, items, size=18, color=DARK, gap=6, bcolor=TEAL):
    """items: str | (lead, rest) | ('-', str) for sub-bullet"""
    tb = s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = tf.margin_right = Inches(0.05)
    first = True
    for it in items:
        p = tf.paragraphs[0] if first else tf.add_paragraph()
        first = False
        p.space_after = Pt(gap)
        sub = False
        if isinstance(it, tuple) and it[0] == "-":
            sub = True
            it = it[1]
        if isinstance(it, tuple):
            lead, rest = it
            r1 = p.add_run()
            r1.text = lead + " "
            r1.font.bold = True
            r1.font.size = Pt(size)
            r1.font.name = FONT
            r1.font.color.rgb = NAVY
            r2 = p.add_run()
            r2.text = rest
            r2.font.size = Pt(size)
            r2.font.name = FONT
            r2.font.color.rgb = color
        else:
            r = p.add_run()
            r.text = it
            r.font.size = Pt(size - 2 if sub else size)
            r.font.name = FONT
            r.font.color.rgb = color
        set_bullet(p, "\u2013" if sub else "\u2022", level_off=0.3 if sub else 0.0,
                   color=bcolor)
    return tb


def new_slide(title, kicker=None, notes=None):
    s = prs.slides.add_slide(BLANK)
    state["n"] += 1
    rect(s, 0, 0, 13.333, 7.5, WHITE)
    rect(s, 0, 0, 13.333, 1.15, NAVY)
    rect(s, 0, 1.15, 13.333, 0.06, TEAL)
    text(s, 0.55, 0.12, 11.6, 0.9, title, size=30, bold=True, color=WHITE,
         anchor=MSO_ANCHOR.MIDDLE)
    if kicker:
        text(s, 9.3, 0.08, 3.7, 0.3, kicker.upper(), size=12, bold=True, color=GOLD,
             align=PP_ALIGN.RIGHT)
    text(s, 0.55, 7.08, 8, 0.3, "Twin Pregnancy | Case Discussion | MS Obstetrics & Gynaecology",
         size=11, color=GREY)
    text(s, 12.0, 7.08, 0.8, 0.3, str(state["n"]), size=11, color=GREY, align=PP_ALIGN.RIGHT)
    if notes:
        s.notes_slide.notes_text_frame.text = notes
    return s


def card(s, x, y, w, h, head, items, hc=TEAL, fill=LIGHT, size=16, gap=4):
    rect(s, x, y, w, h, fill)
    rect(s, x, y, w, 0.5, hc)
    text(s, x + 0.1, y, w - 0.2, 0.5, head, size=17, bold=True, color=WHITE,
         anchor=MSO_ANCHOR.MIDDLE)
    bullets(s, x + 0.1, y + 0.6, w - 0.2, h - 0.65, items, size=size, gap=gap, bcolor=hc)


def table(s, x, y, w, data, colw, rowh=0.5, size=15, head=NAVY, zebra=True, first_bold=True):
    rows, cols = len(data), len(data[0])
    gt = s.shapes.add_table(rows, cols, Inches(x), Inches(y), Inches(w), Inches(rowh * rows))
    t = gt.table
    tblPr = t._tbl.tblPr
    sid = tblPr.find(qn("a:tableStyleId"))
    if sid is not None:
        sid.text = "{5940675A-B579-460E-94D1-54222C63F5DA}"  # no style, table grid
    for i, cw in enumerate(colw):
        t.columns[i].width = Inches(cw)
    for r in range(rows):
        t.rows[r].height = Inches(rowh)
        for c in range(cols):
            cell = t.cell(r, c)
            cell.margin_left = cell.margin_right = Inches(0.08)
            cell.margin_top = cell.margin_bottom = Inches(0.04)
            cell.vertical_anchor = MSO_ANCHOR.MIDDLE
            cell.fill.solid()
            if r == 0:
                cell.fill.fore_color.rgb = head
            else:
                cell.fill.fore_color.rgb = LIGHT if (r % 2 == 1 or not zebra) else WHITE
            tf = cell.text_frame
            tf.word_wrap = True
            p = tf.paragraphs[0]
            run = p.add_run()
            run.text = data[r][c]
            run.font.size = Pt(size)
            run.font.name = FONT
            if r == 0:
                run.font.bold = True
                run.font.color.rgb = WHITE
            else:
                run.font.color.rgb = DARK
                run.font.bold = (c == 0 and first_bold)
    return t


def pic(s, name, x, y, w=None, h=None):
    kw = {}
    if w:
        kw["width"] = Inches(w)
    if h:
        kw["height"] = Inches(h)
    return s.shapes.add_picture(A + name, Inches(x), Inches(y), **kw)


def caption(s, x, y, w, t):
    text(s, x, y, w, 0.5, t, size=12, italic=True, color=GREY)


# ---------------- 1. Title ----------------
s = prs.slides.add_slide(BLANK)
state["n"] += 1
rect(s, 0, 0, 13.333, 7.5, NAVY)
rect(s, 0, 5.2, 13.333, 0.08, TEAL)
rect(s, 0.8, 1.55, 0.12, 2.35, GOLD)
text(s, 1.1, 1.4, 11, 1.2, "Twin Pregnancy", size=60, bold=True, color=WHITE)
text(s, 1.1, 2.65, 11, 0.9, "A Case Discussion: from chorionicity to delivery", size=28, color=RGBColor(0xBF, 0xD9, 0xE6))
text(s, 1.1, 3.4, 11, 0.5, "MS Obstetrics & Gynaecology | Long case with viva points", size=18, color=GOLD, bold=True)
text(s, 1.1, 5.5, 11, 0.5, "Presenter: ____________    Unit: ____________    Date: ____________", size=16,
     color=RGBColor(0xBF, 0xD9, 0xE6))
text(s, 1.1, 6.1, 11, 0.5, "Model case: replace bracketed details with your own patient's findings", size=14, italic=True,
     color=RGBColor(0x8F, 0xA9, 0xBE))
s.notes_slide.notes_text_frame.text = ("Model case. Every patient-specific value (age, Hb, BP, scan results) is an example "
                                       "and must be replaced with your own patient's data before presenting.")

# ---------------- 2. Outline ----------------
s = new_slide("Presentation outline", "Roadmap")
items = [("1", "Case history", TEAL), ("2", "Examination & summary", TEAL), ("3", "Diagnosis & differentials", TEAL),
         ("4", "Embryology & chorionicity", NAVY), ("5", "Complications", NAVY), ("6", "Investigations & surveillance", NAVY),
         ("7", "Antenatal management", CORAL), ("8", "Timing & mode of delivery", CORAL), ("9", "Intrapartum & PPH", CORAL),
         ("10", "Viva points & take-home", GOLD)]
for i, (n, t, c) in enumerate(items):
    col, row = i // 5, i % 5
    x, y = 0.8 + col * 6.1, 1.65 + row * 1.04
    rect(s, x, y, 0.8, 0.8, c, shape=MSO_SHAPE.OVAL)
    text(s, x, y, 0.8, 0.8, n, size=22, bold=True, color=WHITE, align=PP_ALIGN.CENTER, anchor=MSO_ANCHOR.MIDDLE)
    text(s, x + 1.0, y, 4.8, 0.8, t, size=22, color=DARK, anchor=MSO_ANCHOR.MIDDLE)

# ---------------- 3. History ----------------
s = new_slide("Case history", "Part 1",
              "Present the patient as a model case. Stress chorionicity, mode of conception, and symptoms of complications.")
card(s, 0.5, 1.5, 4.0, 5.4, "Patient & complaints", [
    ("Patient:", "Mrs. X, 28 y, G2P1L1, booked"),
    ("Complaints:", "Amenorrhoea 8 months (34 weeks by LMP)"),
    "Abdominal distension more than expected for dates, 1 month",
    "Breathlessness and pedal oedema, 2 weeks",
], size=16)
card(s, 4.7, 1.5, 4.0, 5.4, "Present pregnancy", [
    ("Conception:", "spontaneous [or ART: ovulation induction / IUI / IVF]"),
    ("Dating:", "LMP confirmed by first-trimester CRL scan"),
    ("1st trimester scan:", "DCDA twins, lambda sign"),
    ("Anomaly scan:", "normal; cervical length normal"),
    ("Symptoms:", "no bleeding, leaking or contractions; fetal movements present"),
], hc=NAVY, size=16)
card(s, 8.9, 1.5, 3.95, 5.4, "Risk-factor review", [
    "Hyperemesis, anaemia, pre-eclampsia symptoms",
    "Polyuria or polydipsia (GDM), itching (cholestasis)",
    ("Past:", "no HTN, DM, thyroid, uterine surgery, cone biopsy"),
    ("Family:", "twins on maternal side"),
    ("Obstetric:", "one term vaginal birth, no PPH"),
], hc=CORAL, size=16)

# ---------------- 4. Examination ----------------
s = new_slide("Examination findings", "Part 2",
              "Typical clinical signs: uterus larger than dates (more than 4 cm), 3 or more fetal poles, two FHS with a silent zone.")
card(s, 0.5, 1.5, 4.0, 5.4, "General", [
    "Built moderate, weight gain 14 kg",
    ("Pallor:", "present, Hb 9.5 g/dL"),
    ("BP:", "124/80 mmHg, pulse 92/min"),
    "Oedema: mild pedal; no icterus",
    "CVS, RS: normal",
], size=16)
card(s, 4.7, 1.5, 4.0, 5.4, "Obstetric palpation", [
    ("Inspection:", "ovoid, wide abdomen, tense skin"),
    ("Fundal height:", "38 cm (expected about 34)"),
    ("Girth:", "increased"),
    ("Fundal grip:", "breech"),
    ("Lateral grip:", "many small parts, 3 or more poles"),
    ("Pelvic grip:", "Twin A cephalic, engaged 3/5"),
], hc=NAVY, size=16)
card(s, 8.9, 1.5, 3.95, 5.4, "Auscultation & PV", [
    ("FHS:", "two sounds, 140 and 148 bpm, silent zone between"),
    ("Lie:", "Twin A cephalic, Twin B breech"),
    ("PS/PV:", "cervix closed, uneffaced; membranes intact"),
    ("Pelvis:", "adequate"),
], hc=CORAL, size=16)

# ---------------- 5. Summary & diagnosis ----------------
s = new_slide("Summary and diagnosis", "Part 3",
              "Read the summary aloud in under a minute. This is the part the examiner remembers.")
rect(s, 0.5, 1.5, 12.3, 3.15, PALE_TEAL)
rect(s, 0.5, 1.5, 0.12, 3.15, TEAL)
text(s, 0.8, 1.55, 11.9, 3.05,
     "28-year-old G2P1L1, 34 weeks by LMP, confirmed by early scan, presented with abdominal distension "
     "large for dates and breathlessness. Spontaneous conception. First-trimester scan showed a dichorionic "
     "diamniotic twin pregnancy. On examination: pale (Hb 9.5 g/dL), BP 124/80, fundal height 38 cm, 3 or more "
     "fetal poles, two FHS (140 and 148 bpm) with a silent zone. Twin A cephalic, Twin B breech. Cervix closed.",
     size=18, color=DARK, anchor=MSO_ANCHOR.MIDDLE)
rect(s, 0.5, 4.85, 6.0, 2.05, NAVY)
text(s, 0.7, 4.9, 5.6, 0.4, "DIAGNOSIS", size=14, bold=True, color=GOLD)
text(s, 0.7, 5.25, 5.6, 1.6, "G2P1L1 at 34 weeks, DCDA twin pregnancy, Twin A cephalic and Twin B breech, "
     "with mild anaemia", size=19, bold=True, color=WHITE)
rect(s, 6.8, 4.85, 6.0, 2.05, LIGHT)
text(s, 7.0, 4.9, 5.6, 0.4, "PLAN IN ONE LINE", size=14, bold=True, color=CORAL)
text(s, 7.0, 5.25, 5.6, 1.6, "Treat anaemia, growth scans every 4 weeks, steroid cover if preterm birth "
     "is likely, planned birth at 37 to 38 weeks (vaginal trial since Twin A is cephalic)",
     size=17, color=DARK)

# ---------------- 6. Differential ----------------
s = new_slide("Large-for-dates uterus: differential diagnosis", "Part 3",
              "Always give the differential for a large-for-dates uterus.")
table(s, 0.5, 1.55, 12.3, [
    ["Cause", "Features", "How to separate from twins"],
    ["Wrong dates", "LMP uncertain, normal fetal number", "Early CRL scan"],
    ["Polyhydramnios", "Tense uterus, fluid thrill, hard to feel parts", "Single fetus; AFI above 25 cm"],
    ["Macrosomia / GDM", "One large fetus, maternal diabetes", "Single FHS, EFW above 90th centile"],
    ["Fibroid with pregnancy", "Irregular firm mass separate from fetus", "Ultrasound"],
    ["Molar pregnancy (early)", "Bleeding, high hCG, no fetal parts", "Snowstorm pattern on scan"],
    ["Twin pregnancy", "3 or more poles, 2 FHS, silent zone", "Two sacs and two fetuses on scan"],
], [3.0, 5.0, 4.3], rowh=0.62, size=16)
text(s, 0.5, 6.1, 12.3, 0.8,
     "Clinical clues for twins: fundal height more than 4 cm above gestational age, 3 or more fetal poles, "
     "two FHS with a 10 bpm difference, and a groove between the fetal bodies.",
     size=16, bold=True, color=TEAL)

# ---------------- 7. Embryology ----------------
s = new_slide("Types of twins: zygosity and chorionicity", "Part 4",
              "Timing of division of the monozygotic zygote decides chorionicity and amnionicity. Dizygotic twins are always DCDA.")
pic(s, "zygosity.jpg", 0.5, 1.5, w=6.3)
caption(s, 0.5, 5.35, 6.3, "Dizygotic (a) and monozygotic (b) twinning by timing of division (source: image library).")
table(s, 7.0, 1.55, 5.85, [
    ["Division after fertilisation", "Type"],
    ["Day 0 to 3", "DCDA (about 30%)"],
    ["Day 4 to 8", "MCDA (about 70%)"],
    ["Day 8 to 13", "MCMA (1 to 2%)"],
    ["After day 13", "Conjoined twins"],
], [3.2, 2.65], rowh=0.55, size=16)
bullets(s, 7.0, 4.5, 5.85, 2.4, [
    ("Dizygotic:", "about two thirds; two ova, always DCDA; rises with ART, age and parity"),
    ("Monozygotic:", "about one third; rate constant at 3 to 4 per 1000"),
], size=16)

# ---------------- 8. Chorionicity ----------------
s = new_slide("Why chorionicity matters", "Part 4",
              "Source: Creasy & Resnik's Maternal-Fetal Medicine. Perinatal mortality about 12% MC vs 2 to 5% DC.")
card(s, 0.5, 1.5, 6.0, 3.35, "Monochorionic twins", [
    "About 20% of twin pregnancies but the highest complication rate, due to shared placental anastomoses",
    "Perinatal mortality about 12% vs 2 to 5% in dichorionic twins",
    "Risks: TTTS, TAPS, TRAP, sFGR, co-twin death effects",
], hc=CORAL, size=16)
card(s, 6.8, 1.5, 6.0, 3.35, "Dichorionic twins", [
    "Separate placentas and circulations",
    "Main risks: preterm birth, growth discordance, pre-eclampsia",
    "Surveillance can be less intensive (4-weekly growth scans)",
], hc=TEAL, size=16)
table(s, 0.5, 5.05, 12.3, [
    ["Ultrasound sign (11 to 14 weeks)", "Lambda (twin-peak) sign", "T sign"],
    ["Chorionicity", "Dichorionic", "Monochorionic"],
], [4.5, 4.4, 3.4], rowh=0.55, size=16)
text(s, 0.5, 6.25, 12.3, 0.7,
     "Determine chorionicity in the first trimester. Accuracy falls after 14 weeks. Also count placental masses, "
     "check membrane thickness and fetal sex.", size=15, color=GREY)

# ---------------- 9. Complications ----------------
s = new_slide("Complications of twin pregnancy", "Part 5",
              "Maternal physiology: plasma volume up about 50 to 60%, higher cardiac output, uterine overdistension.")
card(s, 0.5, 1.5, 4.0, 5.4, "Maternal", [
    "Hyperemesis, anaemia",
    "Pre-eclampsia (2 to 3 times)",
    "Gestational diabetes",
    "Polyhydramnios",
    "Cholestasis of pregnancy",
    "Preterm labour, abruption, previa",
    "Operative delivery, PPH",
    "Thromboembolism, postnatal depression",
], size=16)
card(s, 4.7, 1.5, 4.0, 5.4, "Fetal / neonatal", [
    "Preterm birth (about 50% before 37 weeks)",
    "Growth restriction and discordance",
    "Congenital anomalies (about twice as common)",
    "Malpresentation, cord accidents",
    "Perinatal death, cerebral palsy",
    "Single intrauterine fetal death",
], hc=NAVY, size=16)
card(s, 8.9, 1.5, 3.95, 5.4, "Monochorionic only", [
    "TTTS (10 to 15%)",
    "TAPS",
    "TRAP sequence",
    "Selective growth restriction",
    "Co-twin injury after IUFD",
    "Cord entanglement (MCMA)",
], hc=CORAL, size=16)

# ---------------- 10. Investigations ----------------
s = new_slide("Investigations and surveillance schedule", "Part 6",
              "MCDA scanning every 2 weeks from 16 weeks follows RCOG/NICE advice. DCDA every 4 weeks from 20 weeks.")
table(s, 0.5, 1.5, 12.3, [
    ["Time", "DCDA", "MCDA"],
    ["11 to 14 weeks", "Dating by CRL (larger twin), chorionicity, NT", "Same; label twins A and B"],
    ["16 weeks", "Routine antenatal care", "Start 2-weekly scan: liquor, bladder, growth"],
    ["18 to 20 weeks", "Anomaly scan, cervical length", "Anomaly scan, fetal echo, cervical length"],
    ["From 20 to 22 weeks", "Growth scan every 4 weeks", "Growth, liquor, MCA Doppler every 2 weeks"],
    ["24 to 28 weeks", "OGTT, Hb, ferritin", "OGTT, Hb, ferritin"],
], [2.4, 5.0, 4.9], rowh=0.62, size=15)
text(s, 0.5, 5.4, 12.3, 0.4, "Other tests", size=17, bold=True, color=TEAL)
bullets(s, 0.5, 5.8, 12.3, 1.2, [
    "BP and urine protein every visit; urine culture; blood group and Rh; HIV, HBsAg, VDRL, TSH",
    "Third trimester: NST or biophysical profile and Doppler if growth restriction or other complications",
], size=15, gap=3)

# ---------------- 11. Antenatal management ----------------
s = new_slide("Antenatal management", "Part 7",
              "Aspirin guidance differs: NICE says 2 or more risk factors, ACOG says all twins in some guidance.")
card(s, 0.5, 1.5, 6.0, 5.4, "Supportive care", [
    ("Visits:", "every 2 weeks from 20 weeks; weekly in last month"),
    ("Nutrition:", "extra about 300 kcal/day and protein"),
    ("Iron:", "60 mg elemental or more; treat Hb below 11 g/dL"),
    ("Folic acid:", "4 mg; calcium and vitamin D"),
    ("Aspirin:", "75 to 150 mg from 12 weeks if risk factors"),
    ("Rest:", "left lateral position; prophylactic bed rest not proven"),
], size=16)
card(s, 6.8, 1.5, 6.0, 5.4, "Preterm birth preparedness", [
    ("Steroids:", "betamethasone 12 mg IM x 2, 24 h apart, if birth expected before 34 to 35 weeks"),
    ("Magnesium sulphate:", "neuroprotection if birth before 30 to 32 weeks"),
    ("Cerclage:", "not routine; consider in short cervix or past cervical insufficiency"),
    ("Progesterone / pessary:", "no clear benefit in unselected twins"),
    ("Tocolysis:", "nifedipine or atosiban; avoid beta-agonists"),
    ("Counsel:", "warning signs and birth plan"),
], hc=CORAL, size=16)

# ---------------- 12. TTTS ----------------
s = new_slide("Twin-twin transfusion syndrome", "Part 5",
              "Source: Creasy & Resnik's Maternal-Fetal Medicine. TTTS affects 10 to 15% of monochorionic pregnancies. "
              "Laser coagulation improves survival and short-term disability.")
pic(s, "ttts.jpg", 0.5, 1.45, h=5.5)
caption(s, 3.95, 5.8, 2.6, "TTTS at 22 weeks: plethoric recipient and pale donor (Creasy & Resnik).")
bullets(s, 6.7, 1.5, 6.2, 2.6, [
    ("Cause:", "net flow through deep arteriovenous anastomoses in a shared placenta"),
    ("Donor:", "hypovolaemia, oliguria, oligohydramnios, growth restriction"),
    ("Recipient:", "hypervolaemia, polyuria, polyhydramnios, cardiac strain, hydrops"),
    ("Diagnosis:", "MC twins; DVP below 2 cm in one sac and above 8 cm (above 10 cm after 20 weeks) in the other"),
], size=15, gap=4)
table(s, 6.7, 4.35, 6.2, [
    ["Quintero stage", "Feature"],
    ["I", "Oligo/polyhydramnios; donor bladder visible"],
    ["II", "Donor bladder not visible"],
    ["III", "Abnormal Doppler (UA, DV, UV)"],
    ["IV", "Hydrops"],
    ["V", "Death of one or both twins"],
], [1.6, 4.6], rowh=0.42, size=13)
text(s, 6.7, 6.9 - 0.05, 6.2, 0.1, "", size=2)

# ---------------- 13. Other MC complications ----------------
s = new_slide("Other monochorionic complications", "Part 5",
              "Anastomoses image from the image library (placental injection study).")
pic(s, "anastomoses.jpg", 0.5, 1.5, h=4.2)
caption(s, 0.5, 5.75, 4.2, "Dye injection of a shared placenta showing vascular communications.")
table(s, 5.0, 1.5, 7.85, [
    ["Condition", "Key point"],
    ["TAPS", "Tiny anastomoses; Hb discordance, MCA-PSV difference, no liquor discordance"],
    ["TRAP", "Acardiac twin perfused by the pump twin; treat by cord coagulation or ablation"],
    ["sFGR", "EFW of one twin below 10th centile; types I to III by umbilical artery Doppler"],
    ["Single IUFD", "Acute exsanguination of the survivor into the dead twin; brain injury risk"],
    ["MCMA", "Cord entanglement; caesarean at 32 to 34 weeks"],
], [1.9, 5.95], rowh=0.78, size=14)
text(s, 0.5, 6.2, 12.3, 0.7,
     "After single IUFD in MC twins: check MCA-PSV for anaemia, MRI after about 4 weeks, individualise timing, "
     "give steroids. Emergency delivery of the survivor does not undo injury already done.",
     size=14, bold=True, color=CORAL)

# ---------------- 14. Timing of delivery ----------------
s = new_slide("Timing of delivery (uncomplicated twins)", "Part 8",
              "Guidelines differ. Most guidelines advise DCDA birth at 37 to 38 weeks. Quote the guideline your unit follows. "
              "NICE NG137 and ACOG Practice Bulletin 231 are the two usually quoted.")
table(s, 0.5, 1.6, 12.3, [
    ["Type", "NICE NG137 (UK)", "ACOG (USA)"],
    ["DCDA", "Offer birth from 37+0; do not go beyond 37+6", "38+0 to 38+6 weeks"],
    ["MCDA", "36+0 weeks (consider steroids)", "34+0 to 37+6 weeks"],
    ["MCMA", "32+0 to 33+6 weeks with steroid cover", "32+0 to 34+0 weeks"],
    ["Complicated twins", "Individual assessment", "Individualise"],
], [2.6, 5.4, 4.3], rowh=0.75, size=17)
rect(s, 0.5, 5.6, 12.3, 1.2, PALE_CORAL)
text(s, 0.7, 5.65, 11.9, 1.1,
     "Why earlier for MC twins? Fetal death rates are consistently higher in monochorionic than dichorionic twins at all "
     "gestational ages, including in uncomplicated pregnancies.", size=17, color=DARK, anchor=MSO_ANCHOR.MIDDLE)

# ---------------- 15. Mode of delivery ----------------
s = new_slide("Mode of delivery", "Part 8",
              "Twin Birth Study (Barrett 2013): 2800 women, 32 to 38+6 weeks, Twin A cephalic; no difference in perinatal "
              "mortality or serious neonatal morbidity between planned CS and planned vaginal birth.")
table(s, 0.5, 1.55, 12.3, [
    ["Presentation / situation", "Plan"],
    ["Twin A cephalic (any Twin B)", "Planned vaginal birth is appropriate"],
    ["Twin A breech or transverse", "Caesarean section"],
    ["Monoamniotic twins", "Caesarean section (cord entanglement)"],
    ["Placenta previa, classical scar, conjoined twins", "Caesarean section"],
    ["One previous LSCS", "TOLAC possible with counselling; higher rupture risk"],
], [5.6, 6.7], rowh=0.68, size=17)
text(s, 0.5, 5.85, 12.3, 1.0,
     "For our patient: Twin A cephalic, so offer a trial of vaginal birth at 37 to 38 weeks with epidural, "
     "continuous CTG for both twins and readiness for emergency CS.",
     size=18, bold=True, color=TEAL)

# ---------------- 16. Intrapartum ----------------
s = new_slide("Intrapartum care and PPH prevention", "Part 9",
              "A 2024 systematic review confirms an increased risk of PPH in twin pregnancy (PMID 39367324).")
card(s, 0.5, 1.5, 4.0, 5.4, "Preparation", [
    "Unit with theatre, NICU, senior obstetrician and anaesthetist",
    "IV access, blood cross-matched",
    "Epidural early",
    "Continuous CTG for both twins",
    "Ultrasound machine in the room",
    "Two paediatric teams",
], size=15)
card(s, 4.7, 1.5, 4.0, 5.4, "Delivery of Twin B", [
    "Clamp cord of Twin A; check lie by abdomen, PV and scan",
    "Longitudinal lie: wait for contractions or start oxytocin; rupture membranes when engaged",
    "Transverse lie: ECV or internal podalic version with breech extraction",
    "Aim for a short interval; fetal heart rate is the guide",
    "Abnormal CTG or cord prolapse: expedite delivery",
], hc=NAVY, size=15)
card(s, 8.9, 1.5, 3.95, 5.4, "Third stage and PPH", [
    "Oxytocin 10 IU IM or 5 IU IV slowly after Twin B",
    "Ergometrine if not hypertensive; carboprost available",
    "Tranexamic acid ready",
    "Send placentas for chorionicity",
    "Rare: locked twins, abruption after Twin A",
], hc=CORAL, size=15)

# ---------------- 17. Viva ----------------
s = new_slide("High-yield viva questions", "Part 10",
              "Rehearse short answers: each should fit in 30 seconds.")
qa = [
    ("How are twins classified?", "By zygosity, then chorionicity and amnionicity (timing of division)."),
    ("Best time to determine chorionicity?", "11 to 14 weeks: lambda sign (DC), T sign (MC)."),
    ("Which twins need 2-weekly scans?", "Monochorionic, from 16 weeks, for TTTS, sFGR and TAPS."),
    ("When to deliver uncomplicated DCDA / MCDA?", "37 to 38 weeks / 36 to 37 weeks (guideline dependent)."),
    ("Twin A cephalic: mode?", "Planned vaginal birth is appropriate."),
    ("Why avoid beta-agonists in preterm labour?", "Higher plasma volume; risk of pulmonary oedema."),
    ("Treatment of TTTS stage II to IV?", "Fetoscopic laser coagulation (16 to 26 weeks)."),
]
for i, (q, a) in enumerate(qa):
    y = 1.5 + i * 0.77
    rect(s, 0.5, y, 0.45, 0.65, TEAL if i % 2 == 0 else NAVY)
    text(s, 0.5, y, 0.45, 0.65, str(i + 1), size=16, bold=True, color=WHITE, align=PP_ALIGN.CENTER, anchor=MSO_ANCHOR.MIDDLE)
    rect(s, 0.95, y, 11.85, 0.65, LIGHT)
    text(s, 1.1, y, 4.9, 0.65, q, size=15, bold=True, color=NAVY, anchor=MSO_ANCHOR.MIDDLE)
    text(s, 6.1, y, 6.6, 0.65, a, size=15, color=DARK, anchor=MSO_ANCHOR.MIDDLE)

# ---------------- 18. Take home ----------------
s = new_slide("Take-home messages", "Summary")
msgs = [
    ("1", "Chorionicity first", "Confirm it in the first trimester; it drives surveillance and timing."),
    ("2", "Think of the complications", "Anaemia, pre-eclampsia, GDM, preterm birth, growth discordance."),
    ("3", "Monochorionic means closer watch", "2-weekly scans from 16 weeks; know TTTS, TAPS, sFGR."),
    ("4", "Plan delivery early", "Timing by chorionicity; mode by Twin A presentation."),
    ("5", "Be ready for PPH", "Overdistended uterus: active management, blood and tranexamic acid ready."),
]
for i, (n, h, d) in enumerate(msgs):
    y = 1.5 + i * 1.08
    rect(s, 0.5, y, 12.3, 0.95, LIGHT)
    rect(s, 0.5, y, 0.95, 0.95, [TEAL, NAVY, CORAL, TEAL, NAVY][i])
    text(s, 0.5, y, 0.95, 0.95, n, size=28, bold=True, color=WHITE, align=PP_ALIGN.CENTER, anchor=MSO_ANCHOR.MIDDLE)
    text(s, 1.65, y, 4.3, 0.95, h, size=20, bold=True, color=NAVY, anchor=MSO_ANCHOR.MIDDLE)
    text(s, 6.0, y, 6.7, 0.95, d, size=16, color=DARK, anchor=MSO_ANCHOR.MIDDLE)

# ---------------- 19. References ----------------
s = new_slide("References", "Sources")
bullets(s, 0.6, 1.6, 12.1, 5.3, [
    "Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice. Chapters on multiple pregnancy, "
    "monochorionic twins and TTTS (pp. 110, 852, 3292 to 3296).",
    "NICE Guideline NG137. Twin and triplet pregnancy (2019, updated).",
    "ACOG Practice Bulletin No. 231. Multifetal gestations (2021).",
    "RCOG Green-top Guideline No. 51. Management of monochorionic twin pregnancy (2016).",
    "Fox NS et al. Twin pregnancy guidelines review. Am J Obstet Gynecol 2023.",
    "Abdulsalam FAM et al. Twin pregnancy and postpartum haemorrhage: systematic review and meta-analysis. "
    "BMC Pregnancy Childbirth 2024 (PMID 39367324).",
    "Barrett JFR et al. Twin Birth Study. N Engl J Med 2013.",
], size=16, gap=8)

prs.save("/tmp/workspace/twin-pregnancy-ppt/output/Twin_Pregnancy_Case_Discussion.pptx")
print("saved", state["n"])