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

OUTPUT = "/tmp/workspace/ms-obg-exam/MS_OBG_ShortAnswers.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    "Title", parent=styles["Title"],
    fontSize=13, textColor=colors.HexColor("#1a237e"),
    spaceAfter=4, alignment=TA_CENTER
)
subtitle_style = ParagraphStyle(
    "Subtitle", parent=styles["Normal"],
    fontSize=9, textColor=colors.HexColor("#37474f"),
    spaceAfter=2, alignment=TA_CENTER
)
q_style = ParagraphStyle(
    "Question", parent=styles["Normal"],
    fontSize=10, textColor=colors.HexColor("#880000"),
    fontName="Helvetica-Bold", spaceBefore=10, spaceAfter=4,
    leftIndent=0
)
heading_style = ParagraphStyle(
    "Heading", parent=styles["Normal"],
    fontSize=9.5, textColor=colors.HexColor("#1565c0"),
    fontName="Helvetica-Bold", spaceBefore=4, spaceAfter=2
)
body_style = ParagraphStyle(
    "Body", parent=styles["Normal"],
    fontSize=9, textColor=colors.black,
    fontName="Helvetica", leading=13,
    leftIndent=10, spaceAfter=2
)
bullet_style = ParagraphStyle(
    "Bullet", parent=styles["Normal"],
    fontSize=9, textColor=colors.black,
    fontName="Helvetica", leading=13,
    leftIndent=18, bulletIndent=8, spaceAfter=1
)
note_style = ParagraphStyle(
    "Note", parent=styles["Normal"],
    fontSize=8, textColor=colors.HexColor("#555555"),
    fontName="Helvetica-Oblique", leftIndent=10, spaceAfter=2
)

def Q(num, text, marks="10"):
    return Paragraph(f"Q{num}. {text} <font color='#555555' size='8'>[{marks} marks]</font>", q_style)

def H(text):
    return Paragraph(text, heading_style)

def B(text):
    return Paragraph(text, body_style)

def BU(text):
    return Paragraph(f"• {text}", bullet_style)

def HR():
    return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#b0bec5"), spaceAfter=4, spaceBefore=4)

content = []

# Header
content.append(Paragraph("THE WEST BENGAL UNIVERSITY OF HEALTH SCIENCES", title_style))
content.append(Paragraph("M.S. (Obstetrics & Gynaecology) — May–June 2022 | Paper II", subtitle_style))
content.append(Paragraph("Short Answer Key | 15 Minutes per Question | 10 Marks Each", subtitle_style))
content.append(HRFlowable(width="100%", thickness=1.5, color=colors.HexColor("#1a237e"), spaceAfter=8))

# ── Q1 ──────────────────────────────────────────────────────
content.append(Q(1, "Practical Approach to Evaluation & Management of APH"))
content.append(H("Definition"))
content.append(B("Antepartum haemorrhage (APH): bleeding from the genital tract ≥20 weeks gestation before delivery."))
content.append(H("Causes"))
content.append(BU("Placenta praevia (20%) — painless, bright-red, recurrent bleeding"))
content.append(BU("Placental abruption (30%) — painful, dark blood, woody-hard uterus"))
content.append(BU("Local causes: cervical polyp, ectropion, vaginitis"))
content.append(BU("Unexplained / marginal sinus bleed"))
content.append(H("Evaluation"))
content.append(BU("History: pain, quantity, recurrence, trauma, coital bleed"))
content.append(BU("Vitals: BP, pulse, pallor — assess haemodynamic stability"))
content.append(BU("Abdomen: uterine tenderness, tone, lie, presentation, FHR"))
content.append(BU("DO NOT do P/V until placenta praevia excluded by USG"))
content.append(BU("USG: placental localisation, fetal well-being, BPP"))
content.append(BU("Investigations: CBC, coagulation (PT, APTT, fibrinogen), G&S, Kleihauer-Betke"))
content.append(H("Management"))
content.append(BU("Resuscitate: 2 large-bore IV, crystalloids, blood transfusion"))
content.append(BU("Placenta praevia: expectant if stable + <36 wks; LSCS if major/bleeding"))
content.append(BU("Abruption: if mild + term → AROM + oxytocin; if severe → immediate delivery"))
content.append(BU("Treat DIC: FFP, cryoprecipitate, platelets as needed"))
content.append(BU("Postpartum: active management of 3rd stage, watch for PPH"))
content.append(HR())

# ── Q2 ──────────────────────────────────────────────────────
content.append(Q(2, "USG Evaluation of Fetal Hydronephrosis & Outline of Management"))
content.append(H("Definition"))
content.append(B("Dilatation of fetal renal pelvis (APD ≥4 mm in 2nd trimester; ≥7 mm in 3rd trimester)."))
content.append(H("USG Parameters"))
content.append(BU("AP diameter (APD) of renal pelvis — key measurement"))
content.append(BU("Society for Fetal Urology (SFU) grading I–IV"))
content.append(BU("Calyceal dilatation: mild (central only), severe (peripheral + parenchymal thinning)"))
content.append(BU("Ureteric dilatation (hydroureter) → suggests VUJ/UVJ obstruction or VUR"))
content.append(BU("Bladder: size, wall thickness (keyhole sign → posterior urethral valves in male fetus)"))
content.append(BU("Contralateral kidney: size, echogenicity, presence"))
content.append(BU("Amniotic fluid: oligohydramnios → bilateral severe obstruction / renal dysplasia"))
content.append(H("Common Causes"))
content.append(BU("UPJ obstruction (most common, 40–50%)"))
content.append(BU("VUR, UVJ obstruction, posterior urethral valves, multicystic dysplastic kidney"))
content.append(H("Management"))
content.append(BU("Mild (APD <10 mm): serial USG; postnatal USG at 48–72 h and 4–6 wks"))
content.append(BU("Moderate–severe: postnatal VCUG, DTPA/MAG3 renogram, paediatric urology referral"))
content.append(BU("Antenatal intervention (vesicoamniotic shunt) only for bilateral severe obstruction + oligohydramnios"))
content.append(BU("Antibiotic prophylaxis (trimethoprim) postnatally until workup complete"))
content.append(HR())

# ── Q3 ──────────────────────────────────────────────────────
content.append(Q(3, "Fetal ECG (ST Analysis / STAN) as Antepartum Fetal Surveillance"))
content.append(H("Principle"))
content.append(B("Fetal myocardial hypoxia → T-wave changes on fetal ECG. STAN (ST-Analysis) detects T/QRS ratio elevation."))
content.append(H("Components of Fetal ECG Analysis"))
content.append(BU("T/QRS ratio: rises during hypoxia (anaerobic glycolysis → catecholamine surge)"))
content.append(BU("Biphasic ST: associated with chronic hypoxia / acidosis"))
content.append(BU("Combined with CTG for interpretation (STAN system — Neoventa)"))
content.append(H("Indications"))
content.append(BU("High-risk labour (IUGR, post-dates, meconium, abnormal CTG)"))
content.append(BU("Requires internal scalp electrode — so only intrapartum use"))
content.append(H("Advantages"))
content.append(BU("Reduces unnecessary intervention vs. CTG alone"))
content.append(BU("Better positive predictive value for acidosis"))
content.append(H("Limitations"))
content.append(BU("Requires ruptured membranes + ≥2 cm dilation"))
content.append(BU("Not useful < 36 weeks (immature myocardium)"))
content.append(BU("Cannot replace CTG; must be used in conjunction"))
content.append(BU("Limited antepartum use — primarily an intrapartum tool"))
content.append(HR())

# ── Q4 ──────────────────────────────────────────────────────
content.append(Q(4, "Peripartum Cardiomyopathy: Features (3) / Diagnosis (2) / Risks (3) / Treatment (2)"))
content.append(H("Presenting Features [3 marks]"))
content.append(BU("Dyspnoea, orthopnoea, PND — onset last month of pregnancy to 5 months postpartum"))
content.append(BU("Pedal oedema, raised JVP, S3 gallop, cardiomegaly"))
content.append(BU("Systemic embolism, palpitations, reduced exercise tolerance"))
content.append(H("Diagnostic Evaluation [2 marks]"))
content.append(BU("Echocardiography: EF <45%, dilated LV, global hypokinesia — gold standard"))
content.append(BU("ECG: sinus tachycardia, LBBB; CXR: cardiomegaly, pulmonary oedema; BNP elevated"))
content.append(H("Risk Factors [3 marks]"))
content.append(BU("Multiparity, advanced maternal age, Black ethnicity, twin pregnancy"))
content.append(BU("Pre-eclampsia, hypertension, malnutrition, prolonged tocolysis (beta-agonists)"))
content.append(BU("Previous PPCM (recurrence risk 30–50%)"))
content.append(H("Treatment [2 marks]"))
content.append(BU("Heart failure: diuretics (furosemide), beta-blocker (carvedilol/metoprolol), hydralazine + nitrates (avoid ACEi in pregnancy)"))
content.append(BU("ACE inhibitor / ARB postnatally; bromocriptine 2.5 mg BD × 2 wks (prolactin hypothesis); anticoagulation if EF <35%"))
content.append(HR())

# ── Q5 ──────────────────────────────────────────────────────
content.append(Q(5, "Background & Rationale of Preconception Care"))
content.append(H("Definition"))
content.append(B("Preconception care: health promotion + medical, behavioural, social interventions BEFORE conception to improve maternal and neonatal outcomes."))
content.append(H("Background / Rationale"))
content.append(BU("Organogenesis: day 17–56 post-conception — most neural tube defects occur before 28 days (before most women know they are pregnant)"))
content.append(BU("50% of pregnancies are unplanned — planned preconception reduces preventable risks"))
content.append(BU("Folic acid 400 mcg/day reduces NTD by 70% — must start ≥1 month before conception"))
content.append(H("Key Components"))
content.append(BU("Medical: control diabetes (HbA1c <6.5%), epilepsy (switch valproate), thyroid, hypertension"))
content.append(BU("Genetic counselling: sickle cell, thalassaemia, PKU carrier screening"))
content.append(BU("Vaccinations: rubella, varicella, hepatitis B before pregnancy"))
content.append(BU("Lifestyle: BMI optimisation, smoking/alcohol cessation, folic acid + vitamin D"))
content.append(BU("Medications: teratogen review (ACEi, warfarin, retinoids, methotrexate — stop/switch)"))
content.append(BU("Mental health: screen depression/anxiety; domestic violence screening"))
content.append(H("Benefits"))
content.append(BU("Reduces congenital anomalies, preterm birth, maternal mortality"))
content.append(BU("Recommended by WHO, RCOG, ACOG as standard of care"))
content.append(HR())

# ── Q6 ──────────────────────────────────────────────────────
content.append(Q(6, "Management of Pregnancy in a Kidney Transplant Recipient"))
content.append(H("Pre-pregnancy Counselling"))
content.append(BU("Wait ≥1–2 years post-transplant (stable graft function)"))
content.append(BU("Criteria: Cr <1.5 mg/dL, proteinuria <500 mg/day, no rejection in 1 yr, stable immunosuppression"))
content.append(BU("Switch mycophenolate/sirolimus → azathioprine + calcineurin inhibitor (safe in pregnancy)"))
content.append(H("Antenatal Care"))
content.append(BU("Shared care: nephrologist + MFM specialist + obstetrician"))
content.append(BU("Monthly renal function: serum Cr, eGFR, urine protein/creatinine ratio"))
content.append(BU("Blood pressure monitoring — target <140/90; drugs: labetalol, nifedipine, methyldopa"))
content.append(BU("Serial growth scans every 4 weeks (IUGR risk 25%)"))
content.append(BU("Screen for CMV, BK virus, UTI (MSU monthly)"))
content.append(BU("Rejection: biopsy safe in pregnancy; treat with IV methylprednisolone"))
content.append(H("Delivery"))
content.append(BU("Aim for 37–38 weeks; LSCS only for obstetric indications"))
content.append(BU("Transplanted kidney lies in iliac fossa — does NOT obstruct labour"))
content.append(BU("Stress-dose steroids intrapartum if on long-term steroids"))
content.append(H("Postpartum"))
content.append(BU("Breastfeeding: tacrolimus/ciclosporin — low levels in breast milk; generally considered acceptable"))
content.append(BU("Contraception: POP or barrier (avoid COCP — thrombosis + hypertension risk)"))
content.append(HR())

# ── Q7 ──────────────────────────────────────────────────────
content.append(Q(7, "Etiology & Diagnosis of Non-Immune Hydrops Foetalis (NIHF)"))
content.append(H("Definition"))
content.append(B("Abnormal accumulation of fluid in ≥2 fetal compartments (ascites, pleural effusion, pericardial effusion, skin oedema) in absence of red cell alloimmunisation."))
content.append(H("Etiology (NIHF — 80% of all hydrops)"))
content.append(BU("Cardiovascular (30–40%): structural CHD, arrhythmias (SVT, complete heart block), cardiomyopathy"))
content.append(BU("Chromosomal (10–15%): Turner syndrome (45X), Down syndrome, trisomy 18"))
content.append(BU("Haematological: alpha-thalassaemia (Hb Barts), twin-to-twin transfusion syndrome (TTTS)"))
content.append(BU("Infections: parvovirus B19 (aplastic crisis), CMV, toxoplasma, syphilis"))
content.append(BU("Lymphatic dysplasia: congenital lymphedema, cystic hygroma"))
content.append(BU("Pulmonary: CPAM, pulmonary sequestration (mediastinal shift → SVC obstruction)"))
content.append(BU("Metabolic: Gaucher, Niemann-Pick, lysosomal storage disorders"))
content.append(H("Diagnosis"))
content.append(BU("USG: polyhydramnios, placental oedema (>4 cm), fluid in ≥2 compartments, BPP"))
content.append(BU("Echocardiography: structural defects, rhythm"))
content.append(BU("Fetal blood sampling (FBS): Hb, karyotype, viral PCR, metabolic panel"))
content.append(BU("Amniocentesis: karyotype, microarray, parvovirus PCR"))
content.append(BU("Maternal: indirect Coombs (exclude immune), Kleihauer, TORCH screen, Hb electrophoresis"))
content.append(B("Idiopathic: ~20% of NIHF even after full workup."))
content.append(HR())

# ── Q8 ──────────────────────────────────────────────────────
content.append(Q(8, "Management of Pregnant Woman with Congenital Cyanotic Heart Disease"))
content.append(H("Risks"))
content.append(BU("Maternal: cardiac failure, arrhythmia, thromboembolism, infective endocarditis, death"))
content.append(BU("Fetal: IUGR, preterm birth, fetal loss, CHD in offspring (5–50% depending on lesion)"))
content.append(H("Pre-pregnancy Assessment"))
content.append(BU("Cardiopulmonary exercise test, ECG, echo, O2 saturation — WHO class III–IV: advise against pregnancy"))
content.append(BU("Eisenmenger syndrome: maternal mortality 30–50% — pregnancy contraindicated"))
content.append(BU("Tetralogy of Fallot (corrected): relatively well-tolerated"))
content.append(H("Antenatal"))
content.append(BU("Multidisciplinary team: cardiologist, MFM, anaesthetist, neonatologist"))
content.append(BU("O2 saturation monitoring; target SpO2 >85% at minimum"))
content.append(BU("Anticoagulation for cyanotic lesions with polycythaemia (Hct >55%) — LMWH"))
content.append(BU("Avoid iron deficiency — worsens cyanosis and thrombotic risk"))
content.append(BU("Serial fetal growth scans, fetal echo at 20–22 wks"))
content.append(H("Delivery"))
content.append(BU("In a tertiary centre with cardiac ICU"))
content.append(BU("Vaginal delivery preferred; epidural analgesia to avoid pain-induced shunting"))
content.append(BU("Avoid aortocaval compression; left lateral tilt"))
content.append(BU("Avoid Valsalva (bearing down) if significant shunt — assisted 2nd stage"))
content.append(BU("SBE prophylaxis: amoxicillin + gentamicin at delivery for high-risk lesions"))
content.append(HR())

# ── Q9 ──────────────────────────────────────────────────────
content.append(Q(9, "Diagnosis & Management of Bicornuate Uterus with Reproductive Outcome"))
content.append(H("Definition & Classification"))
content.append(B("Bicornuate uterus: incomplete fusion of Mullerian ducts at level of fundus. ASRM Class IV. Bicornuate bicollis (2 cervices) vs. bicornuate unicollis (1 cervix)."))
content.append(H("Diagnosis"))
content.append(BU("3D USG: fundal cleft >1 cm, intercornual angle >105°, 2 separate endometrial cavities — best initial test"))
content.append(BU("MRI: gold standard — shows uterine contour, depth of cleft, cervical anatomy"))
content.append(BU("Hysterosalpingography (HSG): shows 2 divergent cavities (does not differentiate from septate)"))
content.append(BU("Hysteroscopy + laparoscopy: concurrent view of inner cavity + outer contour — definitive"))
content.append(H("Reproductive Outcomes"))
content.append(BU("Recurrent miscarriage (25–30%), preterm delivery (20%), malpresentation (40%)"))
content.append(BU("IUGR, placental abnormalities, retained placenta"))
content.append(H("Management"))
content.append(BU("Asymptomatic / no reproductive failure: observation"))
content.append(BU("Recurrent miscarriage (≥2–3): Strassman metroplasty (open or laparoscopic unification)"))
content.append(BU("No role for hysteroscopic resection (unlike septate uterus)"))
content.append(BU("Cerclage if cervical incompetence coexists"))
content.append(BU("Serial antenatal scans, LSCS if persistent malpresentation at term"))
content.append(HR())

# ── Q10 ──────────────────────────────────────────────────────
content.append(Q(10, "Short Notes: (a) Cord Prolapse [5 marks]  (b) Shoulder Dystocia [5 marks]", "5+5"))

content.append(H("(a) Cord Prolapse"))
content.append(BU("Definition: umbilical cord descends beyond presenting part after ROM"))
content.append(BU("Risk factors: malpresentation (footling breech, transverse lie), multiparity, polyhydramnios, low birth weight, artificial ROM with high head"))
content.append(BU("Diagnosis: FHR deceleration on CTG → VE reveals cord at os or in vagina"))
content.append(BU("Immediate management: CALL HELP — do NOT push cord back"))
content.append(BU("Relieve pressure: elevate presenting part manually, knee-chest position, fill bladder (500 mL saline)"))
content.append(BU("Keep cord warm + moist — do not handle unnecessarily"))
content.append(BU("Definitive: emergency LSCS (Category 1) — aim delivery within 30 minutes"))
content.append(BU("Vaginal delivery if fully dilated + imminent birth (forceps/ventouse)"))

content.append(Spacer(1, 6))
content.append(H("(b) Shoulder Dystocia"))
content.append(BU("Definition: failure of shoulders to deliver after head; requires additional manoeuvres (turtle sign)"))
content.append(BU("Risk factors: fetal macrosomia (>4 kg), gestational diabetes, post-dates, prolonged 2nd stage, instrumental delivery, previous shoulder dystocia"))
content.append(BU("CALL FOR HELP — note time of delivery of head"))
content.append(BU("HELPERR mnemonic:"))
content.append(Paragraph("   H — Call for Help | E — Evaluate for Episiotomy | L — Legs (McRoberts: hyperflexion)", bullet_style))
content.append(Paragraph("   P — Suprapubic Pressure (Rubin) | E — Enter (Rubin II, Woods screw) | R — Remove posterior arm", bullet_style))
content.append(Paragraph("   R — Roll patient (Gaskin all-fours)", bullet_style))
content.append(BU("Last resort: Zavanelli manoeuvre (cephalic replacement) + LSCS; deliberate clavicle fracture"))
content.append(BU("Complications: brachial plexus injury (Erb's palsy), hypoxic-ischaemic encephalopathy, maternal PPH, 4th degree tear"))

content.append(Spacer(1, 10))
content.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#1a237e"), spaceAfter=4))
content.append(Paragraph(
    "West Bengal University of Health Sciences | MS OBG Paper II | May–June 2022 | Short Answer Key",
    subtitle_style
))

doc.build(content)
print(f"PDF generated: {OUTPUT}")