Pregnancy-Induced Hypertension (PIH)

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import PageBreak

OUTPUT = "/home/daytona/workspace/pih-pdf/Pregnancy_Induced_Hypertension.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
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    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.5*cm, bottomMargin=2.5*cm,
    title="Pregnancy-Induced Hypertension",
    author="Orris Medical Reference"
)

W, H = A4
styles = getSampleStyleSheet()

# Custom styles
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bullet_style = ParagraphStyle(
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note_style = ParagraphStyle(
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def h1(text):
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def h2(text):
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def body(text):
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def bullet(text):
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def note(text):
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def source(text):
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def spacer(h=6):
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# --- Table helper ---
TABLE_HEADER_BG = colors.HexColor("#1a3a5c")
TABLE_ALT_BG    = colors.HexColor("#eef4fb")
TABLE_BORDER    = colors.HexColor("#aacce0")

def make_table(headers, rows, col_widths=None):
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    return t

# ===================== BUILD STORY =====================
story = []

# --- Cover block ---
story.append(spacer(20))
story.append(Paragraph("Pregnancy-Induced Hypertension", title_style))
story.append(Paragraph("PIH · Preeclampsia · Eclampsia · HELLP Syndrome", subtitle_style))
story.append(HRFlowable(width="60%", thickness=2, color=colors.HexColor("#1a3a5c"),
                         hAlign="CENTER", spaceAfter=4))
story.append(Paragraph("Medical Reference Summary — Orris AI | June 2026", subtitle_style))
story.append(spacer(10))
story.append(hr())

# ============================================================
# 1. DEFINITION & CLASSIFICATION
# ============================================================
story.append(h1("1. Definition & Classification"))
story.append(body(
    "Hypertension complicates up to <b>8–10% of pregnancies</b> and is divided into distinct categories. "
    "The key differentiator is the gestational age of onset, presence of proteinuria, and evidence of end-organ damage."
))
story.append(spacer(4))
story.append(make_table(
    ["Category", "Definition"],
    [
        ["Gestational Hypertension", "New BP ≥140/90 mm Hg after 20 weeks; resolves postpartum; no proteinuria or end-organ damage"],
        ["Preeclampsia", "Gestational hypertension + proteinuria (>300 mg/24 h) OR end-organ damage after 20 weeks"],
        ["Eclampsia", "New-onset seizures in a patient with signs of preeclampsia"],
        ["Superimposed Preeclampsia", "Chronic hypertension with new-onset proteinuria or sudden BP worsening"],
        ["Chronic/Coincidental Hypertension", "Present before pregnancy or persists >6 weeks postpartum"],
        ["Pregnancy-Aggravated Hypertension", "Chronic hypertension with superimposed preeclampsia or eclampsia"],
    ],
    col_widths=[6, 11]
))
story.append(source("Rosen's Emergency Medicine; Brenner & Rector's The Kidney"))

# ============================================================
# 2. ACOG 2013 DIAGNOSTIC CRITERIA
# ============================================================
story.append(h1("2. ACOG 2013 Diagnostic Criteria for Preeclampsia"))
story.append(body(
    "The 2013 ACOG Task Force updated the diagnostic criteria, allowing preeclampsia to be diagnosed "
    "<b>without proteinuria</b> if severe features are present."
))
story.append(h2("Hypertension (required)"))
story.append(body(
    "SBP ≥140 mm Hg OR DBP ≥90 mm Hg on <b>two occasions ≥4 hours apart</b> in a previously normotensive woman "
    "after 20 weeks gestation. If BP ≥160/105, confirmation may occur within minutes for urgent treatment."
))
story.append(h2("PLUS Proteinuria OR one or more of the following:"))
story.append(make_table(
    ["Feature", "Threshold / Criterion"],
    [
        ["Proteinuria", "≥300 mg/24 h; OR protein:creatinine ratio ≥0.3; OR dipstick 2+"],
        ["Thrombocytopenia", "Platelets ≤100,000/mL"],
        ["Renal insufficiency", "Creatinine >1.1 mg/dL OR doubling of creatinine (no other renal disease)"],
        ["Impaired liver function", "Transaminases (ALT/AST) >2× normal"],
        ["Pulmonary edema", "New onset"],
        ["Cerebral or visual symptoms", "Severe headache, visual disturbances, altered mental status"],
    ],
    col_widths=[5.5, 11.5]
))
story.append(note(
    "Key 2013 update: Proteinuria is NO longer required for diagnosis if severe features are present. "
    "Hyperuricemia is common but is not a diagnostic criterion."
))
story.append(source("Brenner & Rector's The Kidney, Table 48.3; ACOG Obstet Gynecol. 2013;122:1122–1131"))

# ============================================================
# 3. EPIDEMIOLOGY & RISK FACTORS
# ============================================================
story.append(h1("3. Epidemiology & Risk Factors"))
story.append(body(
    "Approximately <b>2–7% of pregnancies</b> are complicated by PIH. Eclampsia remains one of the major causes "
    "of maternal mortality, though its incidence has progressively declined."
))
story.append(h2("High-Risk Groups"))
for item in [
    "Women <b>younger than 20 years</b>",
    "<b>Primigravidas</b>",
    "Twin or molar pregnancies",
    "Hypercholesterolemia, pregestational diabetes, or obesity",
    "Family history of PIH",
    "Chronic hypertension (established risk factor for superimposed preeclampsia)",
    "Underlying renal disease or autoimmune conditions (SLE, antiphospholipid syndrome)",
]:
    story.append(bullet(item))
story.append(source("Rosen's Emergency Medicine, p. 3356; Creasy & Resnik's Maternal-Fetal Medicine"))

# ============================================================
# 4. PATHOPHYSIOLOGY
# ============================================================
story.append(h1("4. Pathophysiology"))
story.append(body(
    "The exact cause remains unknown. The current model is a <b>two-stage hypothesis</b>:"
))
story.append(h2("Stage 1 — Abnormal Placentation (Before 20 Weeks)"))
story.append(body(
    "Inadequate trophoblast invasion of maternal spiral arteries. Normally, these remodel into wide, "
    "low-resistance vessels. In preeclampsia, they remain <b>high-resistance</b>, leading to reduced "
    "uteroplacental perfusion and <b>placental ischemia</b>. Abnormal uterine artery Doppler (increased "
    "resistance) precedes clinical disease."
))
story.append(h2("Stage 2 — Maternal Systemic Syndrome (Clinical Disease)"))
story.append(body(
    "Placental ischemia and syncytiotrophoblast stress trigger release of circulating factors causing "
    "<b>widespread maternal endothelial dysfunction</b>:"
))
for item in [
    "<b>Antiangiogenic factors elevated</b>: sFlt-1 (soluble fms-like tyrosine kinase-1), soluble endoglin",
    "<b>Proangiogenic factors reduced</b>: VEGF (vascular endothelial growth factor), PlGF (placental growth factor)",
    "sFlt-1 acts as a VEGF decoy receptor — in the kidney, free VEGF depletion causes glomerular endotheliosis and proteinuria",
    "Intravascular inflammation, oxidative stress, and coagulation activation",
]:
    story.append(bullet(item))
story.append(h2("Hemodynamic Changes"))
story.append(body(
    "Normal pregnancy = high cardiac output, low peripheral resistance. In preeclampsia: cardiac output is "
    "initially elevated, then peripheral vascular resistance rises sharply. Ultimately cardiac output "
    "<i>falls</i> as resistance continues to rise, causing end-organ ischemia."
))
story.append(h2("End-Organ Effects"))
story.append(make_table(
    ["System", "Manifestation / Mechanism"],
    [
        ["Neurologic", "Focal vasoconstriction → cerebral edema, petechial hemorrhage; headache, cortical blindness, hyperreflexia, seizures; cerebral hemorrhage is a leading cause of death"],
        ["Renal", "Glomerular endotheliosis → proteinuria, oliguria, creatinine rise"],
        ["Hepatic", "Sinusoidal fibrin deposition → transaminitis, RUQ/epigastric pain, subcapsular hematoma"],
        ["Hematologic", "Microangiopathic hemolytic anemia, thrombocytopenia (platelet consumption)"],
        ["Placental", "Infarction, abruption, fetal growth restriction, fetal hypoxia/death"],
        ["Cardiovascular", "Vasospasm, increased afterload, pulmonary edema"],
    ],
    col_widths=[4, 13]
))
story.append(source("Barash Clinical Anesthesia; Brenner & Rector's The Kidney; NKF Primer on Kidney Diseases"))

# ============================================================
# 5. HELLP SYNDROME
# ============================================================
story.append(h1("5. HELLP Syndrome"))
story.append(body(
    "A particularly severe variant of preeclampsia occurring in <b>up to 12% of severe preeclampsia cases</b> "
    "(0.2–0.8% of all pregnancies)."
))
story.append(make_table(
    ["Letter", "Finding", "Diagnostic Threshold"],
    [
        ["H", "Hemolysis", "Microangiopathic hemolytic anemia (schistocytes on smear, elevated LDH, low haptoglobin)"],
        ["EL", "Elevated Liver enzymes", "ALT and AST > 70 U/L"],
        ["LP", "Low Platelets", "< 100,000/mL"],
    ],
    col_widths=[1.5, 5, 10.5]
))
story.append(body(
    "Two major classification systems exist: <b>Tennessee classification</b> and <b>Mississippi classification</b>. "
    "HELLP may present without classic hypertension or proteinuria in some cases, making diagnosis challenging."
))
story.append(source("Rosen's Emergency Medicine; Sleisenger & Fordtran's GI and Liver Disease"))

# ============================================================
# 6. MANAGEMENT
# ============================================================
story.append(h1("6. Management"))
story.append(h2("When to Treat Blood Pressure"))
story.append(body(
    "Initiate antihypertensive therapy when: <b>SBP >160 mm Hg OR DBP >105 mm Hg</b> (acute threshold). "
    "Chronic therapy may begin at lower thresholds based on clinical context. "
    "<b>Goal</b>: Reduce BP by 15–20%, targeting systolic 140–150 mm Hg. "
    "Avoid rapid lowering — risks uterine hypoperfusion and fetal distress."
))
story.append(h2("Drugs to AVOID in Pregnancy"))
story.append(body(
    "<b>ACE inhibitors and ARBs are contraindicated</b> — unequivocal evidence of adverse fetal effects "
    "(renal dysgenesis, oligohydramnios, fetal death)."
))
story.append(h2("Antihypertensive Drug Choices"))
story.append(make_table(
    ["Drug", "Setting", "Dose", "Notes"],
    [
        ["α-Methyldopa", "Outpatient / Chronic", "250 mg twice daily", "Former FDA category B; centrally acting α2-agonist; drug of choice for chronic PIH"],
        ["Labetalol", "Outpatient or Acute IV", "100 mg PO twice daily;\n20 mg IV, escalate to 40 mg at 10 min", "Combined α1/β-blocker; safe; widely used"],
        ["Nifedipine (extended-release)", "Outpatient / Chronic", "30 mg once daily", "Ca²⁺ channel blocker; safe in pregnancy"],
        ["Hydralazine", "Acute / Inpatient IV", "5–10 mg IV or IM; repeat q20 min", "Direct vasodilator; first-line acute IV agent"],
    ],
    col_widths=[3.5, 3.5, 4, 6]
))
story.append(source("Goodman & Gilman's Pharmacological Basis of Therapeutics; Rosen's Emergency Medicine"))

story.append(h2("Seizure Prophylaxis & Treatment: Magnesium Sulfate"))
story.append(note(
    "Magnesium sulfate has LITTLE antihypertensive effect but is the most effective anticonvulsant in eclampsia. "
    "It prevents recurrent seizures while maintaining uterine and fetal blood flow."
))
story.append(body("<b>Indications:</b>"))
for item in [
    "Severe preeclampsia (BP ≥160/110 with symptoms)",
    "CNS manifestations: headache, visual disturbance, altered mental status",
    "Active eclamptic seizures",
    "Postpartum with CNS manifestations (~20% of eclampsia occurs >48 h after delivery)",
]:
    story.append(bullet(item))
story.append(body("<b>Dosing Protocol (Pritchard/Parkland Protocol):</b>"))
story.append(make_table(
    ["Phase", "Dose", "Route", "Duration"],
    [
        ["Loading dose", "4–6 g", "IV", "Over 15–20 minutes"],
        ["Maintenance", "2 g/hr", "IV infusion", "Continued intrapartum and 24 h postpartum"],
    ],
    col_widths=[3.5, 3, 3, 7.5]
))
story.append(h2("Magnesium Toxicity Monitoring"))
story.append(make_table(
    ["Serum Mg²⁺ Level", "Clinical Effect"],
    [
        ["4–7 mg/dL (therapeutic)", "Seizure prophylaxis; normal reflexes"],
        ["~10 mg/dL", "Loss of deep tendon reflexes (early warning sign — STOP infusion)"],
        ["~12 mg/dL", "Respiratory depression"],
        [">15 mg/dL", "Cardiac arrest"],
    ],
    col_widths=[5.5, 11.5]
))
story.append(body(
    "<b>Antidote for hypermagnesemia:</b> Calcium gluconate 1 g IV (given slowly) — reverses "
    "respiratory depression and loss of reflexes."
))
story.append(h2("If Seizures Persist Despite MgSO₄"))
story.append(make_table(
    ["Agent", "Dose"],
    [
        ["Lorazepam", "2–4 mg IV; may repeat ×1 after 10–15 min"],
        ["Phenytoin / Fosphenytoin", "15–20 mg/kg IV ×1; may repeat 10 mg/kg after 20 min"],
        ["Levetiracetam", "20–60 mg/kg IV; may repeat in 12 hours"],
    ],
    col_widths=[6, 11]
))
story.append(note(
    "Always exclude other causes of seizures: hypoglycemia, intracranial hemorrhage, drug overdose."
))
story.append(source("Rosen's Emergency Medicine, p. 3358; Goodman & Gilman's"))

story.append(h2("Definitive Treatment: Delivery"))
story.append(body(
    "<b>Delivery is the only cure for preeclampsia/eclampsia.</b> Decision depends on gestational age "
    "and severity of disease:"
))
story.append(make_table(
    ["Clinical Situation", "Management"],
    [
        ["Severe preeclampsia, mature fetus (≥34 weeks)", "Proceed with delivery (vaginal or cesarean)"],
        ["Severe preeclampsia, premature fetus (<34 weeks)", "Hospitalize; pharmacotherapy; antenatal steroids for fetal lung maturity; aim for further maturation"],
        ["Eclampsia", "Stabilize (MgSO₄ + antihypertensives), then deliver regardless of gestational age"],
        ["HELLP syndrome", "Urgent delivery; consider dexamethasone to improve platelet count"],
    ],
    col_widths=[6, 11]
))

# ============================================================
# 7. POSTPARTUM CONSIDERATIONS
# ============================================================
story.append(h1("7. Postpartum Considerations"))
for item in [
    "PIH and eclampsia can <b>present or worsen postpartum</b> — ~20% of eclampsia occurs >48 hours after delivery",
    "Continue magnesium sulfate for <b>24–48 hours postpartum</b> in women with severe features",
    "Monitor BP closely — can remain elevated for days to weeks",
    "Recurrence rate: ~70% in subsequent pregnancies in women with documented PIH",
    "Long-term cardiovascular risk: preeclampsia is an independent risk factor for hypertension, stroke, and ischemic heart disease later in life",
    "Women with HELLP should be monitored for DIC and renal failure",
]:
    story.append(bullet(item))
story.append(source("Goodman & Gilman's; Creasy & Resnik's Maternal-Fetal Medicine"))

# ============================================================
# 8. PREVENTION
# ============================================================
story.append(h1("8. Prevention"))
story.append(body(
    "No intervention reliably prevents preeclampsia, but the following have evidence of benefit:"
))
story.append(make_table(
    ["Intervention", "Evidence / Population"],
    [
        ["Low-dose aspirin (81 mg/day)", "Recommended from 12–16 weeks in high-risk women (prior preeclampsia, multifetal gestation, chronic hypertension, diabetes, renal disease); NNT ~19 to prevent one case"],
        ["Calcium supplementation", "Benefit in women with low dietary calcium intake (low-resource settings)"],
        ["Antiplatelet agents", "Reported to reduce incidence; mechanism via reduced thromboxane-mediated vasoconstriction"],
        ["Control of modifiable risk factors", "Optimize weight, glycemia, and lipid levels pre-conception"],
    ],
    col_widths=[5.5, 11.5]
))
story.append(source("Creasy & Resnik's Maternal-Fetal Medicine; Goodman & Gilman's"))

# ============================================================
# 9. SUMMARY TABLE
# ============================================================
story.append(h1("9. Quick Reference Summary"))
story.append(make_table(
    ["Parameter", "Key Value / Fact"],
    [
        ["Incidence of PIH", "2–7% of all pregnancies"],
        ["BP threshold for diagnosis", "≥140/90 mm Hg on 2 occasions ≥4 hrs apart (after 20 wks)"],
        ["Proteinuria threshold", ">300 mg/24 h OR P:Cr ratio ≥0.3"],
        ["Threshold to treat BP acutely", "SBP >160 mm Hg OR DBP >105 mm Hg"],
        ["MgSO₄ loading dose", "4–6 g IV over 15–20 min"],
        ["MgSO₄ maintenance dose", "2 g/hr IV"],
        ["Loss of DTRs at Mg level", "~10 mg/dL"],
        ["Respiratory depression at Mg level", "~12 mg/dL"],
        ["Antidote for Mg toxicity", "Calcium gluconate 1 g IV slowly"],
        ["Definitive treatment", "Delivery (only cure)"],
        ["HELLP platelet threshold", "<100,000/mL"],
        ["Post-delivery eclampsia risk", "~20% occurs >48 hrs postpartum"],
    ],
    col_widths=[7, 10]
))

# ============================================================
# SOURCES
# ============================================================
story.append(spacer(12))
story.append(hr())
story.append(Paragraph("<b>References & Sources</b>", ParagraphStyle("RefHead", parent=styles["Normal"],
    fontSize=10, textColor=colors.HexColor("#1a3a5c"), spaceAfter=4)))
for ref in [
    "Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th Ed.",
    "Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th Ed.",
    "Brenner and Rector's The Kidney, 10th Ed. (ACOG 2013 Criteria, Table 48.3)",
    "Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Ed.",
    "NKF Primer on Kidney Diseases, 8th Ed.",
    "Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, 8th Ed.",
    "Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th Ed.",
    "ACOG Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122–1131",
]:
    story.append(Paragraph(f"• {ref}", source_style))

story.append(spacer(8))
story.append(Paragraph(
    "Generated by Orris AI Medical Reference | June 28, 2026",
    ParagraphStyle("Footer", parent=styles["Normal"], fontSize=8,
                   textColor=colors.HexColor("#aaaaaa"), alignment=TA_CENTER)
))

# ===================== BUILD =====================
doc.build(story)
print(f"PDF saved to: {OUTPUT}")