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// ─────────────────────────────────────────────────────────────
// SLIDE 1: TITLE
// ─────────────────────────────────────────────────────────────
titleSlide(
  "POSTPARTUM HAEMORRHAGE",
  "Recognition, Resuscitation & Stepwise Management"
);

// ─────────────────────────────────────────────────────────────
// SLIDE 2: OVERVIEW
// ─────────────────────────────────────────────────────────────
contentSlide("Presentation Overview", [
  "Definition & Classification of PPH",
  "Epidemiology & Global Burden",
  "Pathophysiology — the 4 Ts Framework",
  "Risk Factors",
  "Clinical Recognition & Assessment",
  "Active Management of Third Stage of Labour (AMTSL)",
  "Stepwise Medical Management",
  "Uterotonic Agents — Pharmacology & Dosing",
  "Surgical & Procedural Interventions",
  "Haematological Resuscitation",
  "Specific Causes: Placenta Accreta Spectrum, Uterine Inversion, Coagulopathy",
  "Multidisciplinary Team Approach",
  "Key Guidelines & Recent Evidence",
]);

// ─────────────────────────────────────────────────────────────
// SECTION 1
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 1\nDefinition & Epidemiology");

// SLIDE 3: DEFINITION
contentSlide("Definition of Postpartum Haemorrhage", [
  { text: "Traditional definitions:", bold: true },
  { text: "Blood loss ≥ 500 mL after vaginal delivery", sub: true },
  { text: "Blood loss ≥ 1000 mL after caesarean delivery", sub: true },
  { text: "Clinical (ACOG / WHO preferred) definition:", bold: true },
  { text: "Any blood loss sufficient to cause haemodynamic instability, OR bleeding that COULD cause instability if untreated", sub: true },
  { text: "10% drop in haematocrit, need for packed red cell transfusion, or signs of hypovolaemia", sub: true },
  { text: "Timing classification:", bold: true },
  { text: "Primary (Early) PPH — within the first 24 hours of delivery", sub: true },
  { text: "Secondary (Late) PPH — 24 hours to 6 weeks postpartum", sub: true },
  { text: "Severe PPH — blood loss > 1000 mL", sub: true },
  { text: "Massive PPH — blood loss > 2000 mL or transfusion of ≥ 4 units pRBC", sub: true },
]);

// SLIDE 4: EPIDEMIOLOGY
contentSlide("Epidemiology & Global Burden", [
  "PPH is the leading cause of maternal mortality worldwide",
  "Accounts for approximately 27% of all maternal deaths globally",
  "Incidence: ~1–5% of all deliveries; higher in low-resource settings",
  "In the UK: ~8.9% of deliveries involve PPH (> 500 mL) and ~1.3% severe PPH (> 1500 mL)",
  "Maternal mortality from PPH is 100 times higher in low-income vs high-income countries",
  "A death from PPH occurs every 4 minutes worldwide",
  "Most deaths are preventable with timely recognition and management",
  "Risk is substantially reduced by active management of the third stage of labour (AMTSL)",
], { fs: 15 });

// ─────────────────────────────────────────────────────────────
// SECTION 2
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 2\nThe 4 Ts — Aetiology");

// SLIDE 5: 4Ts Overview
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// SLIDE 6: Uterine Atony detail
contentSlide("Uterine Atony — Pathophysiology & Risk Factors", [
  { text: "Mechanism:", bold: true },
  { text: "Uterus fails to maintain tonic contraction after placental separation", sub: true },
  { text: "Living ligatures (spiral arterioles) remain patent → uncontrolled haemorrhage", sub: true },
  { text: "Normal pregnancy increases uterine blood flow to 600–800 mL/min at term", sub: true },
  { text: "Risk factors for atony:", bold: true },
  { text: "Uterine overdistension — polyhydramnios, macrosomia, multiple gestation", sub: true },
  { text: "Prolonged or rapid labour", sub: true },
  { text: "High parity (grand multipara)", sub: true },
  { text: "Intra-amniotic infection / chorioamnionitis", sub: true },
  { text: "Uterine-relaxing agents (tocolytics, halogenated anaesthetic agents)", sub: true },
  { text: "Oxytocin receptor down-regulation after prolonged oxytocin augmentation", sub: true },
  { text: "Uterine fibroids or structural anomalies", sub: true },
]);

// SLIDE 7: Trauma causes
contentSlide("Trauma — Lacerations & Uterine Inversion", [
  { text: "Genital tract lacerations:", bold: true },
  { text: "Cervical lacerations — especially after rapid delivery or instrumental delivery", sub: true },
  { text: "Vaginal / perineal lacerations graded I–IV", sub: true },
  { text: "Vault lacerations post-caesarean or instrumental delivery", sub: true },
  { text: "Puerperal haematoma:", bold: true },
  { text: "Vulval, paravaginal, or retroperitoneal; may be occult", sub: true },
  { text: "< 4 cm & not expanding → ice packs + observation; larger → incise, irrigate, pack", sub: true },
  { text: "Uterine inversion:", bold: true },
  { text: "Fundus collapses into uterine cavity ± protrudes through cervix", sub: true },
  { text: "Associated with excessive cord traction, uterine-relaxing agents, connective tissue disorders", sub: true },
  { text: "Presents with sudden shock disproportionate to visible blood loss", sub: true },
  { text: "Management: immediate manual repositioning (Johnson manoeuvre); MgSO4/tocolytics to relax uterus", sub: true },
  { text: "Uterine rupture — see dedicated slide", sub: true },
]);

// SLIDE 8: Tissue & Thrombin
twoColSlide(
  "Tissue & Thrombin — Retained Placenta & Coagulopathy",
  [
    "Retained placenta occurs in ~2–3% of deliveries",
    "Failure of placental separation within 30 min = retained placenta",
    "Types: separated but trapped, unseparated, morbidly adherent",
    "Placenta accreta spectrum (PAS):",
    "  Accreta (84%): villi attach to myometrium",
    "  Increta (13%): invades myometrium",
    "  Percreta (3%): through serosa ± adjacent organs",
    "Risk factors for PAS: prior CS, prior uterine surgery, low-lying placenta",
    "Management: manual removal under anaesthesia; PAS may require hysterectomy",
  ],
  [
    "Coagulopathy causes <1% of primary PPH",
    "Consumptive: DIC from abruption, AFE, sepsis, IUFD",
    "Dilutional: massive transfusion without FFP/platelets",
    "Pre-existing: vWD (most common inherited), haemophilia A/B carrier",
    "Screen: PT, aPTT, fibrinogen, D-dimer, platelet count",
    "Critical threshold: fibrinogen < 2 g/L predicts severe PPH",
    "Treatment: FFP, cryoprecipitate, platelets, TXA, PCC if on warfarin",
    "Fibrinogen concentrate: 2–4 g IV in massive PPH",
  ],
  "TISSUE", "THROMBIN"
);

// ─────────────────────────────────────────────────────────────
// SECTION 3
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 3\nRisk Factors & Clinical Recognition");

// SLIDE 9: Risk Factors Table
tableSlide(
  "Risk Factors for Postpartum Haemorrhage",
  ["Category", "Antepartum Risk Factors", "Intrapartum Risk Factors"],
  [
    ["Uterine", "Fibroids, uterine anomalies, polyhydramnios, multiple gestation, macrosomia", "Prolonged / rapid labour, chorioamnionitis, tocolytic use, high parity"],
    ["Placental", "Placenta praevia, low-lying placenta, placenta accreta spectrum, PAS history", "Manual removal of placenta, prolonged 3rd stage (>30 min)"],
    ["Maternal", "Previous PPH, previous CS or uterine surgery, coagulopathy, obesity, anaemia", "Preeclampsia, general anaesthesia, labour augmentation"],
    ["Fetal", "Macrosomia (> 4500 g), multiple gestation, fetal age < 32 weeks", "Instrumental delivery, shoulder dystocia"],
    ["Obstetric", "Grand multiparity (≥ 5), primiparity", "Episiotomy, operative vaginal delivery, cervical/vaginal trauma"],
  ]
);

// SLIDE 10: Clinical Recognition
contentSlide("Clinical Recognition & Assessment", [
  { text: "Signs of haemodynamic instability:", bold: true },
  { text: "Tachycardia is often the FIRST sign (pulse > 100 bpm); BP may be preserved until 30% volume loss", sub: true },
  { text: "Pallor, diaphoresis, altered consciousness, oliguria", sub: true },
  { text: "Hb changes are delayed and unreliable acutely", sub: true },
  { text: "Quantification of blood loss:", bold: true },
  { text: "Visual estimation is notoriously inaccurate (underestimates by 40–50%)", sub: true },
  { text: "Calibrated collection drape (most accurate), weighed swabs (1g = 1 mL), suction canister volume", sub: true },
  { text: "Shock index (HR/SBP) > 1.0 indicates significant haemorrhage", sub: true },
  { text: "Initial investigations:", bold: true },
  { text: "FBC (Hb, platelets), group & crossmatch, coagulation screen (PT, aPTT, fibrinogen), U&E, LFTs", sub: true },
  { text: "Bedside USS — retained products, intrauterine haematoma", sub: true },
  { text: "ABG for lactate, base excess (tissue perfusion marker)", sub: true },
]);

// SLIDE 11: Shock Classification
tableSlide(
  "Classification of Haemorrhagic Shock in PPH",
  ["Class", "Blood Loss", "HR", "BP", "Signs"],
  [
    ["I (Compensated)", "< 750 mL (< 15%)", "< 100", "Normal", "Minimal; slight anxiety"],
    ["II", "750–1500 mL (15–30%)", "100–120", "Normal / narrowing", "Anxiety, tachypnoea, reduced capillary refill"],
    ["III", "1500–2000 mL (30–40%)", "120–140", "Decreased", "Confusion, pallor, tachypnoea, oliguria"],
    ["IV (Critical)", "> 2000 mL (> 40%)", "> 140", "Markedly decreased", "Confusion/unconscious, anuria, imminent death"],
  ]
);

// ─────────────────────────────────────────────────────────────
// SECTION 4
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 4\nPrevention — AMTSL");

// SLIDE 12: AMTSL
contentSlide("Active Management of Third Stage of Labour (AMTSL)", [
  "AMTSL reduces PPH incidence by approximately 2/3 compared with expectant management",
  { text: "Three components of AMTSL:", bold: true },
  { text: "1. Uterotonic administration — oxytocin 10 IU IM (or IV infusion) immediately at/after baby's birth", sub: true },
  { text: "2. Controlled cord traction (CCT) — after signs of placental separation", sub: true },
  { text: "3. Uterine massage — after placental delivery to sustain tone", sub: true },
  { text: "WHO (2012) update — oxytocin alone is the preferred uterotonic (not ergometrine routinely)", bold: false },
  "Early cord clamping (at 1 min) historically included; delayed cord clamping (≥1 min) now preferred when feasible",
  "Carbetocin 100 μg IM is an alternative to oxytocin — longer duration, thermostable formulation (CHAMPION trial)",
  "Heat-stable carbetocin (Merck) now WHO-recommended for settings where cold chain is unreliable",
  "Misoprostol 600 μg oral/sublingual if oxytocin unavailable (lower efficacy, more side effects)",
]);

// ─────────────────────────────────────────────────────────────
// SECTION 5
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 5\nManagement — Stepwise Approach");

// SLIDE 13: Overview of stepwise management
contentSlide("Stepwise Management of PPH — The H-MOAN Framework", [
  { text: "H — Haemorrhage control starts immediately with simultaneous resuscitation", bold: true },
  { text: "Call for help: senior obstetrician, anaesthetist, haematologist, blood bank", sub: true },
  { text: "M — Medical (uterotonic) therapy first-line", bold: true },
  { text: "O — Other non-surgical interventions (tamponade, compression sutures, IR embolisation)", bold: true },
  { text: "A — Advanced surgical intervention (devascularisation, hysterectomy)", bold: true },
  { text: "N — Neonatal / team handover and debrief", bold: true },
  "",
  { text: "Parallel resuscitation at every step:", bold: true },
  { text: "Large-bore IV access (2 x 16G minimum), warm IV fluids, blood products, urinary catheter, O2", sub: true },
  { text: "Activate massive haemorrhage protocol (MHP) early", sub: true },
  { text: "Do not delay surgical intervention waiting for medical therapy to work if bleeding is uncontrolled", sub: true },
], { fs: 15 });

// SLIDE 14: Immediate resuscitation
contentSlide("Immediate Resuscitation — The First 15 Minutes", [
  { text: "Airway & Breathing:", bold: true },
  { text: "High-flow O2 via face mask; anaesthetic team intubate if GCS deteriorating", sub: true },
  { text: "Circulation:", bold: true },
  { text: "2 large-bore IV cannulae (antecubital); consider IO if IV access fails", sub: true },
  { text: "Crystalloid (warmed Hartmann's / lactated Ringer's): initial 1–2 L bolus; avoid excessive crystalloid", sub: true },
  { text: "Transfuse pRBC: target Hb ≥ 8 g/dL during active haemorrhage", sub: true },
  { text: "Use blood warmer; avoid hypothermia (worsens coagulopathy)", sub: true },
  { text: "Monitoring:", bold: true },
  { text: "Continuous pulse oximetry, ECG, NIBP every 5 min → arterial line if haemodynamically unstable", sub: true },
  { text: "Urinary catheter — target urine output ≥ 30 mL/hr", sub: true },
  { text: "Repeat bloods every 30–60 min during active haemorrhage (FBC, coag, fibrinogen, ABG)", sub: true },
  { text: "Tranexamic acid (TXA) 1 g IV over 10 min — give ASAP (within 3 hours of delivery)", bold: true },
]);

// SLIDE 15: Uterotonic Therapy
contentSlide("Uterotonic Agents — Overview", [
  { text: "First-line:", bold: true },
  { text: "Oxytocin 20–40 units in 1 L IV infusion at 125–250 mL/hr; or 10 IU IM", sub: true },
  { text: "Avoid IV bolus — causes hypotension, tachycardia, and ECG changes", sub: true },
  { text: "Second-line (if oxytocin fails):", bold: true },
  { text: "Ergometrine 0.5 mg IM or slow IV (avoid in hypertension — causes vasoconstriction, severe HTN, cerebral vasospasm)", sub: true },
  { text: "Syntometrine (oxytocin + ergometrine) IM — more effective than oxytocin alone but more side effects", sub: true },
  { text: "Carboprost (15-methyl PGF2α / Hemabate) 250 μg IM every 15–90 min (max 8 doses)", sub: true },
  { text: "Contraindicated in asthma; monitor O2 saturation", sub: true },
  { text: "Third-line / adjuncts:", bold: true },
  { text: "Misoprostol 600–1000 μg PR or sublingual (fever, rigors common)", sub: true },
  { text: "Dinoprostone (PGE2) — less commonly used, causes vasodilation — avoid if hypotensive", sub: true },
  { text: "Carbetocin 100 μg IM (prophylaxis; single-dose, thermostable)", sub: true },
], { fs: 14.5 });

// SLIDE 16: Uterotonic drug table
tableSlide(
  "Uterotonic Pharmacology — Quick Reference",
  ["Drug", "Dose & Route", "Onset", "Key Contraindications / Side Effects"],
  [
    ["Oxytocin", "10 IU IM; or 20–40 IU/L IV infusion", "1–3 min IV", "Avoid IV bolus: hypotension, tachycardia, fluid retention"],
    ["Ergometrine", "0.5 mg IM / slow IV", "2–5 min", "Contraindicated: hypertension, pre-eclampsia, Raynaud's. Side effects: N/V, vasoconstriction"],
    ["Carboprost (PGF2α)", "250 μg IM q15–90 min; max 8 doses", "< 5 min", "Contraindicated: asthma. Side effects: bronchospasm, diarrhoea, flushing, O2 desaturation"],
    ["Misoprostol (PGE1)", "600–1000 μg PR / SL / buccal", "< 8 min", "Side effects: fever (38–40°C), rigors, diarrhoea — most common dose-related"],
    ["Carbetocin", "100 μg IM (single dose)", "2 min", "Avoid in hepatic/renal disease. Preferred for prophylaxis in resource-limited settings"],
    ["TXA (adjunct)", "1 g IV over 10 min; repeat at 3 hrs if still bleeding", "Rapid", "Do NOT give after 3 hours of bleeding — increases thromboembolic risk"],
  ]
);

// ─────────────────────────────────────────────────────────────
// SECTION 6
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 6\nSurgical & Procedural Interventions");

// SLIDE 17: Non-surgical procedural
contentSlide("Non-Surgical Interventions — Tamponade & Compression", [
  { text: "Bimanual uterine compression:", bold: true },
  { text: "One fist in anterior fornix, other hand compresses fundus suprapubically", sub: true },
  { text: "Effective temporising measure while awaiting uterotonic effect", sub: true },
  { text: "Intrauterine balloon tamponade:", bold: true },
  { text: "Bakri balloon (500 mL capacity) — uterus-specific; success rate up to 91%", sub: true },
  { text: "Alternatives: Foley catheter, Rüsch balloon, Sengstaken-Blakemore tube, condom catheter", sub: true },
  { text: "Insert into uterine cavity, inflate with warm saline to 250–500 mL, leave in 24 hours", sub: true },
  { text: "Positive 'Tamponade Test' — cessation of bleeding suggests surgical intervention may be avoided", sub: true },
  { text: "Uterine packing:", bold: true },
  { text: "Sterile gauze packing — retrospective evidence supports effectiveness in atony", sub: true },
  { text: "Often used when abdomen is already open (at caesarean)", sub: true },
  { text: "Anti-shock non-pneumatic garment (NASG):", bold: true },
  { text: "Neoprene compression from ankles to navel; autotransfusion effect; useful in resource-limited / transfer settings", sub: true },
]);

// SLIDE 18: Surgical — compression sutures
contentSlide("Uterine Compression Sutures & Devascularisation", [
  { text: "B-Lynch suture (1997):", bold: true },
  { text: "Brace suture placed over uterus to mechanically compress it", sub: true },
  { text: "Original description: bimanual compression first — if this stops bleeding, B-Lynch will likely succeed", sub: true },
  { text: "Suture (Chromic No. 2 or PDS) placed from lower uterine segment, over fundus, and back — bilateral", sub: true },
  { text: "Other compression sutures: Hayman, Pereira, square sutures (B-Lynch variations)", sub: true },
  { text: "Uterine devascularisation:", bold: true },
  { text: "Stepwise uterine devascularisation (O'Leary sutures):", sub: true },
  { text: "Step 1: Bilateral uterine artery ligation (low ligation at level of lower segment)", sub: true },
  { text: "Step 2: Bilateral utero-ovarian ligament ligation", sub: true },
  { text: "Step 3: Internal iliac (hypogastric) artery ligation — reduces pulse pressure in pelvic vessels by ~85%", sub: true },
  { text: "Internal iliac ligation: technically demanding; bilateral required (cross-flow pelvis); 40–50% success rate", sub: true },
  { text: "Uterine artery embolisation (UAE) preferred over surgical ligation in stable patients with IR access", sub: true },
]);

// SLIDE 19: Interventional Radiology
contentSlide("Interventional Radiology — Uterine Artery Embolisation (UAE)", [
  { text: "Role of IR in PPH (RCOG, 2006 onwards):", bold: true },
  { text: "UAE should be available 24/7 ideally; not first-line but not 'last resort'", sub: true },
  { text: "Recommended in stable patients BEFORE hysterectomy to preserve uterus", sub: true },
  { text: "Indications:", bold: true },
  { text: "Failed medical + tamponade therapy; stable enough to transfer to IR suite", sub: true },
  { text: "Post-hysterectomy haemorrhage or vault haemorrhage", sub: true },
  { text: "Prophylactic balloon occlusion in known PAS (placenta accreta) — pre-operative", sub: true },
  { text: "Technique:", bold: true },
  { text: "Bilateral common femoral artery access; catheterise anterior divisions of internal iliac arteries", sub: true },
  { text: "Embolise uterine artery (offending vessel) with Gelfoam (absorbable gelatine sponge)", sub: true },
  { text: "Negative angiogram in atony is common — 'empirical embolisation' of both uterine arteries is accepted practice", sub: true },
  { text: "Success rates: ~90% overall; lower with abnormal placentation (PAS)", sub: true },
  { text: "Failure: proceed to hysterectomy; recurrent bleeding usually amenable to repeat embolisation", sub: true },
]);

// SLIDE 20: Peripartum Hysterectomy
contentSlide("Peripartum Hysterectomy — Last Resort but Life-Saving", [
  { text: "Indications:", bold: true },
  { text: "Uterine atony — failed all medical + surgical measures", sub: true },
  { text: "Placenta accreta spectrum (PAS) — often planned in advance", sub: true },
  { text: "Uterine rupture with uncontrollable haemorrhage", sub: true },
  { text: "Septic uterus", sub: true },
  { text: "Surgical principles:", bold: true },
  { text: "Total vs subtotal (supracervical) hysterectomy — subtotal is faster and may be preferred in extremis", sub: true },
  { text: "Control bilateral uterine arteries early", sub: true },
  { text: "Beware of ureter (bladder dissection especially in PAS with bladder invasion)", sub: true },
  { text: "Cell salvage can be considered if available and massive haemorrhage anticipated", sub: true },
  { text: "Post-operative ICU care, VTE prophylaxis, DIC management", sub: true },
  { text: "Morbidity and mortality data:", bold: true },
  { text: "Incidence: 1–2 per 1000 deliveries in the UK; rising with CS rates and PAS", sub: true },
  { text: "Associated with bladder/ureter injury, DIC, ICU admission; mortality ~1–2% in high-resource settings", sub: true },
], { fs: 14.5 });

// ─────────────────────────────────────────────────────────────
// SECTION 7
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 7\nHaematological Management");

// SLIDE 21: Blood products
contentSlide("Haematological Resuscitation & Massive Haemorrhage Protocol", [
  { text: "Activate Massive Haemorrhage Protocol (MHP) when:", bold: true },
  { text: "Blood loss > 1500 mL or anticipated to exceed 2000 mL", sub: true },
  { text: "Ongoing haemorrhage with haemodynamic instability", sub: true },
  { text: "Transfusion of ≥ 4 units pRBC within 4 hours", sub: true },
  { text: "Fixed-ratio haemostatic resuscitation (damage control resuscitation):", bold: true },
  { text: "pRBC : FFP : Platelets = 1:1:1 (evidence from PROPPR trial)", sub: true },
  { text: "Targets: Hb ≥ 8 g/dL | Fibrinogen ≥ 2 g/L | Platelets ≥ 50 × 10⁹/L | PT/aPTT ≤ 1.5× normal", sub: true },
  { text: "Specific products:", bold: true },
  { text: "Cryoprecipitate: 2 pools (10 units) → raises fibrinogen by ~1 g/L; give when fibrinogen < 2 g/L", sub: true },
  { text: "Fibrinogen concentrate: 2–4 g IV — faster to reconstitute than cryo; licensed for acquired hypofibrinogenaemia", sub: true },
  { text: "PCC (4-factor): if on warfarin; 25–50 IU/kg IV", sub: true },
  { text: "rFVIIa (NovoSeven): last resort adjunct; 90 μg/kg IV — use only after adequate fibrinogen and platelets", sub: true },
  { text: "Avoid hypothermia (< 35°C), acidosis (pH < 7.1), hypocalcaemia — the lethal triad of coagulopathy", sub: true },
]);

// SLIDE 22: TXA evidence
contentSlide("Tranexamic Acid (TXA) in PPH — Evidence Summary", [
  { text: "Mechanism:", bold: true },
  { text: "Competitively inhibits plasminogen activation → prevents fibrinolysis → stabilises clot", sub: true },
  { text: "WOMAN Trial (Lancet, 2017) — 20,060 women, 21 countries:", bold: true },
  { text: "TXA (1 g IV within 3 hours) significantly reduced death due to bleeding: RR 0.81 (95% CI 0.65–1.00)", sub: true },
  { text: "Most benefit when given within 3 hours of delivery", sub: true },
  { text: "No increase in thromboembolic events", sub: true },
  { text: "TXA for PPH prevention (Cheema et al., 2023 — Meta-analysis, Cochrane):", bold: true },
  { text: "Prophylactic TXA at CS significantly reduces intraoperative blood loss and need for transfusion", sub: true },
  { text: "Cochrane Network Meta-analysis (Gallos et al., 2025):", bold: true },
  { text: "Carbetocin + TXA among the most effective combinations for PPH prevention after CS", sub: true },
  { text: "Current recommendation:", bold: true },
  { text: "Give TXA 1 g IV as soon as PPH is diagnosed (ideally within 3 hours); repeat at 3 hours if bleeding persists", sub: true },
], { fs: 15 });

// ─────────────────────────────────────────────────────────────
// SECTION 8
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 8\nSpecific Causes");

// SLIDE 23: Placenta Accreta Spectrum
contentSlide("Placenta Accreta Spectrum (PAS)", [
  { text: "Pathophysiology:", bold: true },
  { text: "Defect in decidua basalis → abnormal invasion of chorionic villi into/through myometrium", sub: true },
  { text: "Accreta (84%) → Increta (13%) → Percreta (3%: through serosa, into bladder/bowel)", sub: true },
  { text: "Risk factors:", bold: true },
  { text: "Previous caesarean section (risk rises exponentially: 1 CS → 0.3%; 4 CS → 10%+)", sub: true },
  { text: "Placenta praevia with prior CS — up to 40–67% risk if praevia + prior CS", sub: true },
  { text: "Prior uterine surgery (myomectomy, curettage, Asherman's syndrome)", sub: true },
  { text: "Antenatal diagnosis:", bold: true },
  { text: "USS: loss of retroplacental clear space, lacunar flow, bladder wall irregularity, 'moth-eaten' placenta", sub: true },
  { text: "MRI: confirms extent of invasion, especially posterior and lateral for planning", sub: true },
  { text: "Management:", bold: true },
  { text: "Multidisciplinary team: obstetrician, interventional radiologist, urologist, haematologist, anaesthetist", sub: true },
  { text: "Planned preterm CS (34–36 weeks) — avoid attempting manual placental removal", sub: true },
  { text: "Consider leaving placenta in situ ('conservative management') or hysterectomy (most common)", sub: true },
], { fs: 14.5 });

// SLIDE 24: Secondary PPH
contentSlide("Secondary Postpartum Haemorrhage (Late PPH)", [
  { text: "Definition: PPH occurring 24 hours to 6 weeks after delivery", bold: true },
  { text: "Causes:", bold: true },
  { text: "Subinvolution of the placental site — most common; endometrium fails to regenerate at implantation site", sub: true },
  { text: "Retained placental tissue or membranes", sub: true },
  { text: "Genital tract infection / endomyometritis", sub: true },
  { text: "Hereditary coagulopathy (e.g. vWD — may not manifest until post-delivery oestrogen withdrawal)", sub: true },
  { text: "Presentation:", bold: true },
  { text: "Increased or renewed PV bleeding after initial decline; may be accompanied by fever/offensive lochia", sub: true },
  { text: "Investigations:", bold: true },
  { text: "FBC, coagulation, blood culture, HVS, pelvic USS (retained products)", sub: true },
  { text: "Management:", bold: true },
  { text: "Antibiotics (broad-spectrum) if infection suspected", sub: true },
  { text: "Uterotonic agents (ergometrine, misoprostol) — promote involution", sub: true },
  { text: "Surgical evacuation under USS guidance if retained products confirmed", sub: true },
  { text: "Hysteroscopy if persistent or unexplained bleeding", sub: true },
]);

// ─────────────────────────────────────────────────────────────
// SECTION 9
// ─────────────────────────────────────────────────────────────
sectionDivider("SECTION 9\nTeam, Protocols & Guidelines");

// SLIDE 25: MDT Approach
contentSlide("Multidisciplinary Team (MDT) Approach", [
  { text: "Immediate team activation:", bold: true },
  { text: "Senior obstetrician / consultant on call", sub: true },
  { text: "Obstetric anaesthetist (airway, haemodynamic management)", sub: true },
  { text: "Midwife coordinator + bedside midwives", sub: true },
  { text: "Haematologist / blood bank (MHP activation)", sub: true },
  { text: "Interventional radiologist (UAE, iliac balloon)", sub: true },
  { text: "Neonatologist if preterm delivery", sub: true },
  { text: "ICU team for post-operative care", sub: true },
  { text: "Communication protocols:", bold: true },
  { text: "SBAR communication tool between team members", sub: true },
  { text: "Dedicated scribe documents all interventions, fluid balance, drug doses with times", sub: true },
  { text: "Blood bank: uncrossmatched O-negative blood available within 10 min; fully crossmatched within 40 min", sub: true },
  { text: "Regular team drills & simulation (ALSO, MOET courses) — proven to reduce PPH mortality", sub: true },
]);

// SLIDE 26: Algorithm / flowchart
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    { label: "STEP 3\n(15–45 min)", text: "Balloon tamponade\n(Bakri 250–500 mL)\nUterine packing\nIR embolisation\nif available & stable", color: "7B0000" },
    { label: "STEP 4\n(45–90 min)", text: "Laparotomy:\nB-Lynch suture\nO'Leary ligation\nInternal iliac ligation\nHysterectomy if all fails", color: "3A0000" },
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// SLIDE 27: Special scenarios
twoColSlide(
  "Special Scenarios in PPH Management",
  [
    "Anticoagulated patient:",
    "  Stop heparin; protamine 1 mg per 100 IU heparin",
    "  Warfarin: 4-factor PCC + Vit K 10 mg IV",
    "  DOACs: specific reversal (idarucizumab, andexanet alfa)",
    "Jehovah's Witness:",
    "  Respect refusal of blood products",
    "  Pre-discuss advanced directives antenatally",
    "  Cell salvage, EPO, iron, embolisation options",
    "  Seek senior/legal advice if unconscious",
    "Multiple gestation:",
    "  Higher atony risk; have uterotonics ready",
    "  Second twin — ensure fundal contraction after each birth",
  ],
  [
    "Amniotic fluid embolism (AFE):",
    "  Sudden cardiovascular collapse in labour",
    "  Followed by DIC — manage coagulopathy aggressively",
    "  C-section if cardiac arrest occurs",
    "  ECMO considered in refractory arrest",
    "Sepsis-related PPH:",
    "  Broad-spectrum antibiotics immediately",
    "  Source control (evacuation of retained products)",
    "  Sepsis 6 bundle; ICU involvement",
    "Placental abruption + PPH:",
    "  Severe abruption depletes fibrinogen rapidly",
    "  Treat DIC aggressively with cryoprecipitate",
    "  Monitor fibrinogen every 30 min",
  ],
  "Specific Scenarios", "Specific Scenarios"
);

// SLIDE 28: Prevention Strategies
contentSlide("Prevention of PPH — Bundle Approach", [
  { text: "Antenatal optimisation:", bold: true },
  { text: "Treat iron-deficiency anaemia (Hb < 110 g/L in 1st/3rd trimester, < 105 g/L in 2nd)", sub: true },
  { text: "Identify and counsel women with PAS risk factors", sub: true },
  { text: "Platelet-rich plasma / autologous blood donation in selected high-risk cases", sub: true },
  { text: "Intrapartum care:", bold: true },
  { text: "Active management of third stage (AMTSL) — oxytocin 10 IU IM routinely", sub: true },
  { text: "Avoid prolonged third stage (> 30 min)", sub: true },
  { text: "Gentle controlled cord traction after uterine contraction; avoid cord avulsion", sub: true },
  { text: "Careful repair of all lacerations, inspect placenta for completeness", sub: true },
  { text: "Healthcare system level:", bold: true },
  { text: "Regular PPH drills and simulation", sub: true },
  { text: "Unit-level PPH algorithm and protocol with clearly assigned roles", sub: true },
  { text: "Audit of peripartum hysterectomy rates as proxy marker for PPH management quality (RCOG)", sub: true },
  { text: "Checklists and safety huddles during high-risk deliveries", sub: true },
]);

// SLIDE 29: Key guidelines
contentSlide("Key Guidelines & Recent Evidence (2023–2025)", [
  { text: "WHO Guidelines (2023):", bold: true },
  { text: "Oxytocin remains gold standard for AMTSL; heat-stable carbetocin in resource-limited settings", sub: true },
  { text: "TXA 1 g IV within 3 hours — all PPH cases", sub: true },
  { text: "ACOG Practice Bulletin No. 183 (2017, reaffirmed 2023):", bold: true },
  { text: "Quantitative blood loss assessment recommended over estimation", sub: true },
  { text: "Fixed-ratio transfusion (1:1:1) in massive PPH", sub: true },
  { text: "RCOG Green-top Guideline No. 52 (Prevention & Management of PPH):", bold: true },
  { text: "Staged approach; IR embolisation as uterus-preserving option", sub: true },
  { text: "Recent evidence:", bold: true },
  { text: "Gallos et al. (Cochrane, 2025) — Network meta-analysis: carbetocin + TXA most effective for prevention", sub: true },
  { text: "Cheema et al. (Am J Obstet Gynecol MFM, 2023) — TXA reduces blood loss and transfusion at CS (meta-analysis)", sub: true },
  { text: "WOMAN Trial (Lancet, 2017 / cited 2023 guidelines) — TXA reduces death from bleeding (RR 0.81)", sub: true },
], { fs: 15 });

// ─────────────────────────────────────────────────────────────
// SLIDE 30: Take-home / Summary
// ─────────────────────────────────────────────────────────────
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    "PPH is the leading cause of maternal death worldwide — most deaths are preventable",
    "The 4 Ts (Tone, Trauma, Tissue, Thrombin) guide rapid systematic diagnosis",
    "Active management of third stage (oxytocin ± TXA) is the single most effective preventive measure",
    "Bimanual compression + oxytocin + call for HELP must happen simultaneously in the first 5 minutes",
    "Give TXA 1 g IV as soon as PPH is diagnosed — effect diminishes beyond 3 hours",
    "Balloon tamponade (Bakri) is a highly effective bridge to definitive management",
    "Activate MHP early — fixed-ratio 1:1:1 (pRBC:FFP:PLT); fibrinogen ≥ 2 g/L is critical",
    "Do not delay hysterectomy if all other measures have failed — it is life-saving",
    "PAS requires antenatal diagnosis, MDT planning, and specialist centre delivery",
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  s.addText("Sources: WHO | ACOG PB-183 | RCOG GTG-52 | WOMAN Trial | Cochrane Reviews 2023–2025", { x: 0.5, y: 4.7, w: 9, h: 0.6, fontSize: 11, color: C.softRed, fontFace: "Calibri", italic: true, align: "center" });
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// SLIDE 31: References
contentSlide("References & Further Reading", [
  "WHO. Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. 2012 (updated guidelines 2023).",
  "ACOG Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130:e168–e186.",
  "RCOG Green-top Guideline No. 52: Prevention and Management of Postpartum Haemorrhage. 2016.",
  "Shakur H et al. (WOMAN Trial). Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage. Lancet. 2017;389:2105–2116.",
  "Gallos ID et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2025;(4). PMID 40237648.",
  "Cheema HA et al. Tranexamic acid for the prevention of blood loss after cesarean section: updated systematic review and meta-analysis. Am J Obstet Gynecol MFM. 2023. PMID 37311484.",
  "Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, 8th ed.",
  "Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th ed.",
  "B-Lynch C et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage. BJOG. 1997;104:372.",
  "Grainger & Allison's Diagnostic Radiology: Interventional Radiology in PPH. 7th ed.",
], { fs: 13 });

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