cd /home/daytona/workspace/attachments/96ab8966-fcad-48c7-8b5e-b020f76b31a8 && p…

embryo oocyte cryopreservation outcomes pregnancy

premature ovarian insufficiency diagnosis management guidelines

vasa previa diagnosis management outcomes

endometriosis classification diagnosis treatment guidelines

PMTCT HIV pregnancy antiretroviral guidelines

BRCA ovarian cancer genetic counselling hereditary

kangaroo mother care neonatal outcomes preterm

NOTES natural orifice transluminal endoscopic surgery gynaecology 2023 2024 guidelines review

India government anemia prevention schemes pregnant women 2022 2023 POSHAN anaemia mukt bharat

publication ethics plagiarism ICMJE COPE guidelines research 2022 2023

BRCA hereditary ovarian cancer genetic testing management

ls /home/daytona/workspace/

mkdir -p /home/daytona/workspace/DNB-OBG-Dec22-P4 && ls /home/daytona/skills/doc…

ls /home/daytona/skills/docx/scripts/ && node --version

mkdir -p /home/daytona/workspace/DNB-OBG-Dec22-P4 && ls /home/daytona/workspace/…

~/DNB-OBG-Dec22-P4/generate_doc.js

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// ──────────────────────────────────────────────────────────────────────────────
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// ── TITLE PAGE ───────────────────────────────────────────────────────────────
content.push(
  new Paragraph({
    children: [new TextRun({ text: 'DNB OBSTETRICS & GYNAECOLOGY', bold: true, size: 40, color: '1F3864' })],
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  new Paragraph({
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  new Paragraph({
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  new Paragraph({
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// ─────────────────────────────────────────────────────────────────────────────
// QUESTION 1
// ─────────────────────────────────────────────────────────────────────────────
content.push(
  new Paragraph({
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  }),

  heading2('INTRODUCTION'),
  para('Cryopreservation is the process of preserving biological material (embryos, oocytes, sperm, ovarian tissue) at ultra-low temperatures (-196°C in liquid nitrogen) to halt all biological activity. It is a cornerstone of modern Assisted Reproductive Technology (ART) and is endorsed by ESHRE, ASRM, and ICMR guidelines.'),

  heading2('A. EMBRYO CRYOPRESERVATION'),

  heading3('1. Methods of Embryo Freezing'),
  mkTable(
    ['Method', 'Principle', 'Cooling Rate', 'Survival Rate', 'Current Status'],
    [
      ['Slow Freezing (Controlled Rate Freezing)', 'Stepwise cooling with low cryoprotectant concentration', '0.3–2°C/min', '60–80%', 'Largely replaced by vitrification'],
      ['Vitrification (Glass-ification)', 'Ultra-rapid cooling preventing ice crystal formation', '>10,000°C/min', '90–97%', 'GOLD STANDARD — ESHRE 2023'],
      ['Open vs Closed Carrier Vitrification', 'Open: direct LN2 contact; Closed: no contact', 'Variable', 'Comparable', 'Closed preferred for infection risk'],
    ],
    [2500, 2000, 1500, 1500, 1900]
  ),

  heading3('2. Stage of Embryo at Freezing'),
  mkTable(
    ['Stage', 'Day', 'Advantage', 'Survival Rate'],
    [
      ['Pronuclear (2PN)', 'Day 1', 'Highest freeze tolerance', '85–90%'],
      ['Cleavage stage (4–8 cell)', 'Day 2–3', 'Good viability', '80–85%'],
      ['Blastocyst', 'Day 5–6', 'Best implantation rates post-thaw (preferred)', '90–95%'],
    ],
    [2500, 1500, 2500, 1800]
  ),
  guideline('ESHRE 2023: Blastocyst-stage vitrification preferred for freeze-all strategy and elective frozen embryo transfer (eFET) cycles.'),

  heading3('3. Cryoprotectants Used'),
  bullet('Permeating (intracellular): Dimethyl sulfoxide (DMSO), Ethylene glycol, Propylene glycol, Glycerol'),
  bullet('Non-permeating (extracellular): Sucrose, Trehalose, Raffinose'),

  heading2('B. OOCYTE CRYOPRESERVATION'),

  heading3('1. Why Oocytes are Harder to Freeze than Embryos'),
  bullet('Large cell volume — more prone to ice crystal formation'),
  bullet('Metaphase II spindle is temperature-sensitive — can be disrupted by cold'),
  bullet('Zona pellucida hardening may reduce fertilization rates'),
  bullet('High water content — risk of chilling injury'),
  note('Post-vitrification MII spindle reassembly occurs in >90% of cases within 3h of warming (ASRM 2021).'),

  heading3('2. Current Technique: Mature Oocyte Vitrification (MII stage)'),
  bullet('Ovarian stimulation → egg retrieval → vitrification at MII stage'),
  bullet('Warming → ICSI (preferred over conventional IVF for vitrified oocytes)'),
  bullet('Fertilization rates post-vitrification: 71–79% (comparable to fresh)'),
  bullet('Clinical pregnancy rates: ~40–50% per transfer (ASRM Committee Opinion 2021)'),

  heading3('3. Indications for Oocyte Cryopreservation'),
  mkTable(
    ['Category', 'Indication'],
    [
      ['Oncofertility', 'Preservation before chemotherapy / radiotherapy'],
      ['Social/Elective', 'Fertility preservation for personal/career reasons'],
      ['Religious/Ethical', 'Objection to embryo freezing'],
      ['Ovarian reserve concerns', 'Women with diminishing ovarian reserve, BRCA mutation carriers'],
      ['Donor egg banking', 'Third-party reproduction programs'],
      ['IVF cycle — no sperm on day of retrieval', 'Emergency oocyte banking'],
    ],
    [3000, 6000]
  ),
  guideline('ASRM 2021: Oocyte cryopreservation is no longer considered experimental. It should be offered to all women facing gonadotoxic treatment.'),
  guideline('ESHRE Fertility Preservation Guideline 2020/2023: Vitrification of mature oocytes is the recommended standard; ovarian tissue cryopreservation remains experimental in adults but may be preferred in prepubertal girls.'),

  heading2('C. LENGTH OF SUCCESSFUL PRESERVATION'),
  mkTable(
    ['Material', 'Reported Successful Storage Duration', 'Key Evidence'],
    [
      ['Embryos', 'Up to 10–20+ years; live births reported from embryos stored >20 years', 'Riggs et al., Fertil Steril 2010 — births from 19-year-old embryos'],
      ['Oocytes', 'Up to 10+ years with no significant decline in competence', 'Cobo et al., Fertil Steril 2020'],
      ['Sperm', 'Theoretically indefinite at -196°C; clinical use up to 21+ years', 'BFS guidelines 2019'],
      ['Ovarian tissue', 'Up to 10 years; viability maintained', 'ESO/ESHRE 2022'],
    ],
    [2000, 4000, 3000]
  ),
  bold('Key Principle: At -196°C, metabolic activity is ZERO. Theoretically, biological material can be stored indefinitely without further deterioration. The limiting factor is not time, but quality of material at time of freezing.'),
  note('HFEA (UK) regulations: embryo storage is legally limited to 10 years (extendable to 55 years for medical reasons). Indian ICMR (2021 ART Act): embryo storage up to 5 years, extendable on consent.'),

  heading2('D. FACTORS INFLUENCING PREGNANCY OUTCOME'),
  mkTable(
    ['Factor', 'Impact on Outcome', 'Details'],
    [
      ['Patient Age at Freezing', 'MOST IMPORTANT', 'Younger age = better oocyte quality. Success rate: <35y: 40–50%; 35–37y: 30–40%; 38–40y: 20–30%; >40y: <15% per transfer'],
      ['Vitrification vs Slow Freeze', 'Major', 'Vitrification gives 10–15% higher survival and pregnancy rates vs slow freeze'],
      ['Stage of embryo', 'Significant', 'Blastocyst > cleavage > pronuclear for implantation rates'],
      ['Embryo quality (morphology)', 'Significant', 'Gardner grading for blastocysts — 4AA/5AA best outcomes'],
      ['Lab technique & equipment', 'Significant', 'Quality of cryoprotectant, carrier device, warming protocol'],
      ['Endometrial preparation for FET', 'Significant', 'Natural cycle vs HRT cycle — natural cycle preferred if ovulatory (RCT evidence)'],
      ['Number of embryos transferred', 'Significant', 'Single embryo transfer (SET) is now ESHRE/ASRM standard for first FET in good prognosis'],
      ['Cause of infertility', 'Moderate', 'Male factor IVF outcomes better than tubal/endometriosis for FET'],
      ['BMI of recipient', 'Moderate', 'Obesity (BMI >30) reduces implantation rates by 10–15%'],
      ['Smoking/alcohol', 'Moderate', 'Smoking reduces success by 30–50%'],
      ['Number of oocytes vitrified', 'For oocyte freezing', '8–12 MII oocytes recommended for reasonable cumulative live birth rate'],
      ['Post-warm survival rate', 'Critical', 'Target >80% for oocytes; >90% for blastocysts'],
    ],
    [2500, 2000, 4900]
  ),

  heading2('E. FET (FROZEN EMBRYO TRANSFER) PROTOCOL OPTIONS'),
  mkTable(
    ['Protocol', 'Method', 'Advantage', 'Guideline Preference'],
    [
      ['Natural Cycle FET', 'Monitor natural ovulation; transfer 5d after LH surge (blastocyst)', 'No drugs, physiologic, better obstetric outcomes', 'ESHRE 2023 — preferred in ovulatory women'],
      ['Modified Natural Cycle FET', 'Natural + hCG trigger', 'More predictable timing', 'Acceptable'],
      ['Artificial (HRT) Cycle FET', 'Estradiol + Progesterone; endometrium prepared', 'Programmable schedule; for anovulatory women', 'Standard in PCOS, POI, anovulation'],
      ['Stimulated Cycle FET', 'Mild stimulation + transfer', 'Rarely used', 'Not routine'],
    ],
    [2000, 2500, 2500, 2400]
  ),
  guideline('ESHRE PGT Consortium 2023 & Cochrane 2022: Natural cycle FET is associated with lower risk of hypertensive disorders of pregnancy and preterm birth compared to artificial FET.'),

  heading2('F. OUTCOME DATA — KEY STATISTICS'),
  bullet('Vitrified embryo FET live birth rate: 35–45% per transfer (SART 2022)'),
  bullet('Vitrified oocyte live birth rate: ~35–40% per transfer if <35 years (ESHRE 2023)'),
  bullet('Cumulative live birth rate with 8–10 vitrified oocytes (<35y): ~65–70%'),
  bullet('Neonatal outcomes: No increased risk of major congenital anomalies in FET vs fresh transfer (Systematic Review, Ozgur et al., 2022)'),
  bullet('Obstetric risk: Slight increase in LGA babies, hypertensive disorders with artificial FET cycles (ESHRE 2023) — under investigation'),

  heading2('SUMMARY TABLE — EXAM READY'),
  mkTable(
    ['Topic', 'Key Point'],
    [
      ['Best method', 'Vitrification (Gold Standard)'],
      ['Best stage to freeze embryo', 'Blastocyst (Day 5–6)'],
      ['Most important factor for success', 'Age at time of freezing'],
      ['Duration of storage', 'Theoretically indefinite at -196°C; legally governed by country'],
      ['Standard FET protocol (ovulatory)', 'Natural cycle FET (ESHRE 2023)'],
      ['Oocyte vitrification status', 'No longer experimental (ASRM 2021)'],
      ['Key guideline', 'ESHRE ART Guideline 2023, ASRM Committee Opinion 2021'],
    ],
    [3000, 6400]
  ),
  divider(),
);

// ─────────────────────────────────────────────────────────────────────────────
// QUESTION 2
// ─────────────────────────────────────────────────────────────────────────────
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  }),

  heading2('PART A: DIAGNOSTIC CRITERIA OF POI'),
  guideline('Based on: ESHRE POI Guideline 2016, updated 2023 (ESHRE-ASRM-CREWHIRL-IMS Joint Guideline, Fertil Steril 2025; PMID 39652037)'),

  heading3('Definition'),
  para('Premature Ovarian Insufficiency (POI) — previously termed premature ovarian failure or premature menopause — is defined as loss of normal ovarian function before the age of 40 years.'),

  heading3('Diagnostic Criteria (ESHRE 2023)'),
  mkTable(
    ['Criterion', 'Threshold / Detail'],
    [
      ['Age', '< 40 years'],
      ['Menstrual irregularity', 'Oligomenorrhoea / amenorrhoea for ≥ 4 months'],
      ['Biochemical confirmation (FSH)', 'Elevated FSH > 25 IU/L on TWO occasions, ≥ 4 weeks apart'],
      ['Estradiol', 'Low/menopausal level (usually E2 < 50 pmol/L, but not mandatory for diagnosis)'],
      ['AMH', 'Very low / undetectable — reflects markedly reduced follicular pool (supportive, not diagnostic alone)'],
    ],
    [3000, 6400]
  ),
  note('Both FSH measurements must be > 25 IU/L (some older texts used > 40 IU/L — current ESHRE threshold is > 25 IU/L for higher sensitivity).'),
  note('Spontaneous intermittent ovarian activity occurs in ~50% of women with POI — hence pregnancy is possible in ~5–10%.'),

  heading2('PART B: EVALUATION AND MANAGEMENT OF POI'),

  heading2('I. EVALUATION OF POI'),

  heading3('A. History'),
  bullet('Age of onset, menstrual history (primary/secondary amenorrhoea)'),
  bullet('Family history of POI, fragile X syndrome, early menopause'),
  bullet('History of autoimmune diseases (thyroid, Addison\'s, T1DM, SLE)'),
  bullet('History of prior pelvic surgery, radiation, chemotherapy (gonadotoxic treatment)'),
  bullet('Symptoms: hot flushes, night sweats, vaginal dryness, mood changes, cognitive symptoms, sexual dysfunction'),
  bullet('Desire for fertility / contraception needs'),

  heading3('B. Investigations'),
  mkTable(
    ['Investigation', 'Purpose / Expected Finding'],
    [
      ['FSH (×2, ≥4 weeks apart)', 'Confirm diagnosis: FSH > 25 IU/L'],
      ['LH', 'Elevated (LH:FSH ratio often <1 in POI, unlike PCOS where LH > FSH)'],
      ['Estradiol (E2)', 'Low (menopausal range)'],
      ['AMH', 'Markedly low / undetectable'],
      ['Prolactin', 'Rule out hyperprolactinaemia'],
      ['TSH, Free T4', 'Rule out thyroid dysfunction (common comorbidity)'],
      ['Fasting glucose / HbA1c', 'Screen for T1DM (autoimmune)'],
      ['Adrenal antibodies (21-hydroxylase)', 'If positive → refer endocrinology; risk of Addison\'s disease'],
      ['Anti-thyroid antibodies (TPO-Ab)', 'Screen for autoimmune thyroiditis'],
      ['Karyotype (all women ≤35y)', 'Detect Turner syndrome (45,X or mosaics), structural X abnormalities'],
      ['FMR1 premutation testing (Fragile X)', 'ESHRE recommends offering to all women with spontaneous POI'],
      ['DEXA scan (bone mineral density)', 'Baseline BMD — high risk of osteoporosis'],
      ['Pelvic ultrasound', 'Antral follicle count, ovarian volume (often low); exclude other pathology'],
      ['Adrenal CT/MRI', 'If adrenal antibodies positive, or clinical suspicion of Addison\'s'],
      ['Echocardiogram', 'If Turner syndrome confirmed — rule out bicuspid aortic valve, aortic coarctation'],
    ],
    [3000, 6400]
  ),
  guideline('ESHRE POI Guideline 2023: All women with spontaneous POI should be offered karyotyping and FMR1 premutation testing. Anti-adrenal antibody testing (21-hydroxylase antibodies) should be offered to detect subclinical autoimmune adrenal insufficiency (risk ~3%).'),

  heading2('II. MANAGEMENT OF POI'),

  heading3('A. Breaking the Diagnosis — Psychological Support'),
  bullet('POI is a life-altering diagnosis — psychological distress, grief, identity issues, sexual dysfunction'),
  bullet('Offer counselling — individual, couple, or group'),
  bullet('Connect with peer support groups (e.g., Daisy Network UK, POI Foundation India)'),
  bullet('Address concerns about fertility, sexuality, premature ageing'),

  heading3('B. Hormone Replacement Therapy (HRT) — CORNERSTONE OF MANAGEMENT'),
  mkTable(
    ['Aspect', 'Recommendation (ESHRE 2023)'],
    [
      ['Indication', 'ALL women with POI (unless contraindicated) — for symptom relief AND long-term health protection'],
      ['Start age', 'As soon as diagnosis confirmed'],
      ['Duration', 'Continue until average age of natural menopause (50–51 years) — do NOT stop early'],
      ['Preferred formulation', 'Transdermal estrogen (gel, patch) + cyclic/continuous progestogen (if uterus intact)'],
      ['Estrogen dose', 'Higher than standard HRT: 100 mcg patch or 2–4 pumps gel daily (physiologic replacement)'],
      ['Progestogen (if uterus present)', 'Micronized progesterone 200 mg days 1–12 of month (preferred for breast/CV safety)'],
      ['No uterus', 'Estrogen only'],
      ['COCP as alternative', 'Acceptable for young women desiring contraception — but transdermal E preferred for bone/CV protection'],
      ['Bone protection', 'HRT is the primary treatment — bisphosphonates only if HRT not tolerated'],
    ],
    [3000, 6400]
  ),
  guideline('ESHRE 2023 & British Menopause Society 2024: HRT in POI is NOT the same as HRT in natural menopause. It is physiologic REPLACEMENT therapy, and the benefits far outweigh risks. The breast cancer risk associated with HRT in natural menopause does NOT apply to POI women on HRT up to age 51.'),

  heading3('C. Fertility Management'),
  mkTable(
    ['Option', 'Success Rate / Notes'],
    [
      ['Spontaneous conception', '5–10% lifetime chance — contraception only if truly not desired'],
      ['Ovarian stimulation / IUI / IVF with own eggs', 'Very poor response; not generally recommended unless residual follicles on USS'],
      ['Oocyte/embryo donation (IVF-OD)', 'BEST option — cumulative LBR ~50–60% per cycle; recommended by ESHRE as primary fertility treatment'],
      ['Ovarian tissue transplantation', 'Experimental; may restore function; used in cancer survivors'],
      ['Adoption / surrogacy', 'Discussed as alternatives'],
    ],
    [3000, 6400]
  ),
  note('Women with POI must be told they are NOT infertile — spontaneous pregnancy occurs in ~5–10%. Reliable contraception is needed if pregnancy not desired.'),

  heading3('D. Bone Health'),
  bullet('DEXA scan at diagnosis and every 2–5 years'),
  bullet('Adequate calcium intake: 1000–1200 mg/day (diet + supplements)'),
  bullet('Vitamin D: 800–1000 IU/day'),
  bullet('HRT is the primary bone-protective treatment — bisphosphonates reserved for when HRT is contraindicated/refused'),
  bullet('Weight-bearing exercise encouraged'),

  heading3('E. Cardiovascular Health'),
  bullet('POI associated with 2× risk of cardiovascular disease (premature estrogen deficiency)'),
  bullet('HRT until age 51 is cardioprotective in POI (unlike natural menopause HRT)'),
  bullet('Screen and manage CV risk factors: BP, lipids, glucose, BMI, smoking'),
  bullet('Annual BP check; lipid profile every 2–3 years'),

  heading3('F. Sexual Health'),
  bullet('Genitourinary syndrome of menopause (GSM): vaginal dryness, dyspareunia, recurrent UTI'),
  bullet('Local vaginal estrogen (pessary, cream, ring) — safe even in women on systemic HRT'),
  bullet('Lubricants and moisturisers as adjuncts'),
  bullet('Psychosexual counselling if needed'),

  heading3('G. Thyroid and Adrenal Monitoring'),
  bullet('Annual TSH check (high risk of autoimmune thyroiditis)'),
  bullet('If anti-adrenal antibodies positive: annual assessment for Addison\'s disease (morning cortisol, synacthen test)'),

  heading3('H. Turner Syndrome Specific'),
  bullet('Cardiac MRI every 5–10 years (aortic complications)'),
  bullet('Echocardiography at diagnosis'),
  bullet('Renal ultrasound at diagnosis'),
  bullet('Annual audiometry (sensorineural hearing loss common)'),
  bullet('Growth hormone assessment in childhood/adolescence'),

  heading2('MANAGEMENT FLOWCHART — POI'),
  mkTable(
    ['Step', 'Action'],
    [
      ['1', 'Confirm diagnosis: FSH >25 IU/L ×2, ≥4 weeks apart, age <40y, ≥4 months menstrual irregularity'],
      ['2', 'Investigations: karyotype, FMR1, anti-adrenal Ab, thyroid Ab, DEXA, pelvic USS'],
      ['3', 'Psychosocial support + counselling'],
      ['4', 'Start HRT immediately (transdermal estrogen + cyclic progesterone if uterus intact)'],
      ['5', 'Discuss fertility options (donor egg IVF is best option)'],
      ['6', 'Calcium + Vitamin D supplementation'],
      ['7', 'Annual follow-up: TSH, BP, lipids, bone health, psychological wellbeing'],
      ['8', 'Continue HRT until age 51 — do NOT stop prematurely'],
    ],
    [1000, 8400]
  ),
  guideline('Key Guideline: ESHRE-ASRM-CREWHIRL-IMS Evidence-based Guideline on POI, Fertil Steril 2025 (PMID 39652037)'),
  divider(),
);

// ─────────────────────────────────────────────────────────────────────────────
// QUESTION 3
// ─────────────────────────────────────────────────────────────────────────────
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    children: [new TextRun({ text: '(a) Write a note on role of Umbilical Coiling Index and its significance. [3 Marks]\n(b) Discuss types of cord insertion. [2 Marks]\n(c) Discuss diagnosis and management of vasa previa. [5 Marks]', bold: true, italics: true, size: 24, color: '1F3864' })],
    spacing: { before: 120, after: 240 },
  }),

  heading2('PART A: UMBILICAL COILING INDEX (UCI)'),

  heading3('Definition'),
  para('The Umbilical Coiling Index is a measure of the helical coiling of the umbilical cord vessels. It is calculated as:'),
  new Paragraph({
    children: [new TextRun({ text: 'UCI = Total number of complete coils of umbilical cord ÷ Total length of cord (in cm)', bold: true, size: 22, color: '1F3864' })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 100, after: 100 },
  }),
  bullet('Normal UCI: 0.17–0.24 coils/cm (i.e., approximately 1 coil per 5 cm)'),
  bullet('Average cord length at term: ~55–60 cm; average ~11 coils'),

  heading3('Classification'),
  mkTable(
    ['Category', 'UCI Value', 'Clinical Association'],
    [
      ['Hypocoiled / Non-coiled', '< 0.10 coils/cm (< 10th percentile)', 'Increased perinatal morbidity, fetal distress, stillbirth'],
      ['Normocoiled', '0.10–0.30 coils/cm (10th–90th percentile)', 'Normal outcome'],
      ['Hypercoiled', '> 0.30 coils/cm (> 90th percentile)', 'Fetal growth restriction, meconium, fetal acidosis, stillbirth'],
    ],
    [2200, 3200, 4000]
  ),

  heading3('How to Calculate UCI on Ultrasound (Antenatal)'),
  bullet('Identify coils on ultrasound in a longitudinal or transverse section of cord'),
  bullet('Antenatal UCI = Coils counted in 9 cm segment ÷ 9 cm (or measured segment)'),
  bullet('Postnatal UCI = Counted from the total cord post-delivery'),
  bullet('Color Doppler: count color alternations in a segment (each alternation = half a coil)'),

  heading3('Clinical Significance of UCI'),
  mkTable(
    ['UCI Type', 'Associated Risks'],
    [
      ['Hypocoiled cord', '- Fetal heart rate abnormalities (late decelerations)\n- Fetal distress in labour\n- Intrauterine fetal demise (IUFD)\n- Preterm birth\n- Cord prolapse (due to lax cord)\n- Meconium-stained liquor'],
      ['Hypercoiled cord', '- Fetal growth restriction (FGR)\n- Fetal hypoxia / acidosis\n- Meconium aspiration\n- True knot formation\n- Fetal demise\n- Oligohydramnios'],
      ['Normocoiled cord', '- Normal perinatal outcomes in general'],
    ],
    [2500, 6900]
  ),
  note('UCI is a gross pathological finding measured postnatally; antenatal estimation is less reliable. However, serial Doppler assessment of cord coiling can serve as a marker in high-risk pregnancies.'),

  heading2('PART B: TYPES OF CORD INSERTION'),
  mkTable(
    ['Type', 'Description', 'Incidence', 'Clinical Significance'],
    [
      ['Central / Eccentric Insertion', 'Cord inserts into central or slightly off-centre area of placenta', 'Most common (>90%)', 'Normal; no significant risk'],
      ['Marginal Insertion (Battledore placenta)', 'Cord inserts at edge/margin of placenta', '~7%', 'Higher risk of fetal distress, cord compression, preterm labour'],
      ['Velamentous Insertion', 'Umbilical vessels travel unsupported through membranes before reaching placenta', '1–2% singletons; up to 15% in twins', 'HIGH RISK — risk of vasa previa, vessel rupture, fetal haemorrhage, FGR, IUFD'],
      ['Furcate Insertion', 'Cord vessels divide before reaching the placenta with partial loss of Wharton\'s jelly', 'Rare', 'Risk of vessel compression, thrombosis, fetal compromise'],
      ['Interstitial Insertion', 'Cord enters placental substance laterally', 'Very rare', 'Usually associated with velamentous insertion complications'],
    ],
    [2000, 2800, 1500, 3100]
  ),
  guideline('ACOG Practice Bulletin No. 183 (2018, reaffirmed 2023): Velamentous cord insertion is a significant risk factor for vasa previa and should be sought on routine anomaly scan.'),
  note('In monochorionic-diamniotic (MCDA) twins, velamentous insertion is seen in up to 10–15% — increases risk of twin-to-twin transfusion syndrome (TTTS) and adverse outcomes.'),

  heading2('PART C: VASA PREVIA — DIAGNOSIS AND MANAGEMENT'),

  heading3('Definition'),
  para('Vasa previa is a condition in which fetal blood vessels (from velamentous cord insertion or succenturiate lobe) run through the fetal membranes across or near the internal cervical os, unsupported by placental tissue or Wharton\'s jelly, placing them at risk of rupture during membrane rupture or labour.'),

  heading3('Types of Vasa Previa'),
  mkTable(
    ['Type', 'Description'],
    [
      ['Type 1', 'Velamentous cord insertion — vessels travel through membranes to placenta over the os'],
      ['Type 2', 'Vessels connecting a succenturiate (accessory) lobe cross over the os'],
    ],
    [1500, 7900]
  ),

  heading3('Risk Factors'),
  bullet('Velamentous cord insertion'),
  bullet('Low-lying placenta / placenta previa (resolved)'),
  bullet('Succenturiate placental lobe'),
  bullet('Multiple pregnancy (twins — especially MCDA, IVF pregnancies)'),
  bullet('IVF pregnancies (2–4× higher risk)'),
  bullet('Bilobed placenta'),
  bullet('Multiparity, previous uterine surgery'),

  heading3('Diagnosis of Vasa Previa'),
  heading3('A. Ultrasound Diagnosis'),
  mkTable(
    ['Modality', 'Findings'],
    [
      ['Transvaginal Ultrasound (TVUS) — GOLD STANDARD', 'Echogenic linear structure near or over internal os on grey-scale USS'],
      ['Color Doppler TVUS', 'Confirms fetal blood flow within the suspicious vessels — sinusoidal or pulsatile waveform confirming fetal circulation'],
      ['Pulsed Doppler', 'Fetal heart rate waveform in the vessel (confirms fetal origin)'],
      ['3D USS / Power Doppler', 'Better delineation of vessel course; useful for surgical planning'],
    ],
    [3500, 6000]
  ),
  guideline('SOGC Clinical Practice Guideline 2017, RCOG Green-Top Guideline 27b (2018): TVUS + Color Doppler is the recommended standard for antenatal diagnosis of vasa previa.'),
  guideline('ISUOG Practice Guidelines 2020: Routine second-trimester anomaly scan should include assessment of cord insertion site; if low-lying or velamentous, TVUS for vasa previa screening is recommended.'),

  heading3('B. Intrapartum Diagnosis (if not known antenatally — EMERGENCY)'),
  bullet('Painless vaginal bleeding at membrane rupture'),
  bullet('Fetal bradycardia / sinusoidal CTG pattern immediately after membrane rupture'),
  bullet('Apt test (Sodium hydroxide / Alkali denaturation): fetal Hb resists denaturation → pink; maternal Hb → brown/yellow'),
  bullet('Kleihauer-Betke test: detects fetal red cells in maternal blood'),
  bullet('Amniscopy: visualization of vessels over os (rarely used now)'),
  note('Intrapartum diagnosis carries near-100% fetal mortality without immediate intervention. Perinatal mortality in undiagnosed vasa previa: 60–75% (Heyborne, Obstet Gynecol 2023, PMID 37535966).'),

  heading3('Management of Vasa Previa'),

  heading3('A. Antenatal Management'),
  mkTable(
    ['Aspect', 'Recommendation (RCOG 2018 / SOGC 2017 / ACOG 2023)'],
    [
      ['Confirm diagnosis', 'TVUS + Color Doppler at 28–32 weeks to confirm persistence and proximity to os'],
      ['Hospitalization', 'Considered at 28–34 weeks (inpatient vs outpatient debate — systematic review 2024, PMID 38057179: outpatient monitoring acceptable for low-risk cases with close surveillance)'],
      ['Steroids', 'Antenatal corticosteroids (betamethasone 12mg ×2, 24h apart) at 28–34 weeks for fetal lung maturity'],
      ['Fetal surveillance', 'Weekly CTG; kick charts; growth scan every 3–4 weeks'],
      ['Cervical length monitoring', 'TVUS CL monitoring — shorten CL increases risk of preterm rupture'],
      ['Activity restriction', 'Pelvic rest; avoid intercourse; avoid prolonged standing/exercise'],
      ['Patient counselling', 'Emergency plan: report to hospital IMMEDIATELY for any bleeding, leaking, contractions, CTG abnormality'],
    ],
    [2500, 6900]
  ),

  heading3('B. Timing of Delivery'),
  mkTable(
    ['Scenario', 'Recommended Delivery Gestation'],
    [
      ['Vasa previa alone (no other complications)', '34–36 weeks (RCOG: 34–35 weeks; ACOG: 34–37 weeks individualized)'],
      ['Vasa previa + preterm labour / bleeding', 'Immediate delivery regardless of gestation'],
      ['Vasa previa + cervical shortening (<15mm)', 'Consider earlier delivery at 32–34 weeks'],
    ],
    [3500, 6000]
  ),
  guideline('RCOG Green-Top 27b 2018: Elective LSCS at 34–36 weeks is recommended for confirmed vasa previa. Antenatal corticosteroids should be given before delivery.'),

  heading3('C. Mode of Delivery'),
  bullet('CAESAREAN SECTION is MANDATORY — vaginal delivery is absolutely contraindicated'),
  bullet('Planned, elective LSCS reduces perinatal mortality from 75% (undiagnosed) to <3% (diagnosed, planned CS)'),
  bullet('Classical CS / lower segment CS depending on placental and vessel location'),
  bullet('Blood products (PRBC O negative) must be available in operating theatre for immediate neonatal transfusion'),
  bullet('Neonatologist must be present at delivery'),

  heading3('D. Intrapartum Emergency (Undiagnosed Vasa Previa)'),
  bullet('IMMEDIATE caesarean section under general anaesthesia'),
  bullet('Neonatal resuscitation team on standby'),
  bullet('O-negative blood for neonatal transfusion'),
  bullet('Do NOT rupture membranes artificially in any case with unexplained vessels near os'),

  heading2('OUTCOMES WITH ANTENATAL DIAGNOSIS'),
  mkTable(
    ['Scenario', 'Perinatal Mortality'],
    [
      ['Undiagnosed vasa previa (intrapartum rupture)', '60–75%'],
      ['Antenatally diagnosed, planned CS 34–35 weeks', '2–3%'],
      ['Inpatient vs outpatient (Laiu et al., 2024, PMID 38057179)', 'No significant difference in outcomes — outpatient management acceptable with strict surveillance'],
    ],
    [3500, 6000]
  ),
  divider(),
);

// ─────────────────────────────────────────────────────────────────────────────
// QUESTION 4
// ─────────────────────────────────────────────────────────────────────────────
content.push(
  new Paragraph({
    children: [new TextRun({ text: 'QUESTION 4 (10 Marks)', bold: true, size: 28, color: '7B2C2C' })],
    spacing: { before: 400, after: 120 },
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    children: [new TextRun({ text: '(a) Describe briefly the components of publication ethics. [4 Marks]\n(b) Enumerate the types of plagiarism. [3 Marks]\n(c) Discuss methods to avoid plagiarism. [3 Marks]', bold: true, italics: true, size: 24, color: '1F3864' })],
    spacing: { before: 120, after: 240 },
  }),

  heading2('PART A: COMPONENTS OF PUBLICATION ETHICS'),
  guideline('Based on: ICMJE Recommendations 2024, Committee on Publication Ethics (COPE) Guidelines 2023, WAME (World Association of Medical Editors) Guidelines'),

  heading3('1. Authorship'),
  mkTable(
    ['ICMJE Criteria — ALL 4 must be met for Authorship', ''],
    [
      ['1', 'Substantial contributions to conception/design OR acquisition/analysis/interpretation of data'],
      ['2', 'Drafting OR critically revising the work for important intellectual content'],
      ['3', 'Final approval of the version to be published'],
      ['4', 'Agreement to be accountable for all aspects of the work (accuracy and integrity)'],
    ],
    [500, 9000]
  ),
  bullet('Ghost authorship: Named contributor who did not meet ICMJE criteria — unethical'),
  bullet('Gift/Honorary authorship: Added for seniority/favour without contribution — unethical'),
  bullet('Ghost-writing: Paid writer not credited — unethical in medical publishing'),
  bullet('Order of authorship: By contribution (first = major contributor; last = senior/corresponding)'),

  heading3('2. Conflict of Interest (COI) Disclosure'),
  bullet('Financial: Funding from industry, honoraria, stock ownership, patents'),
  bullet('Non-financial: Personal relationships, academic competition, institutional affiliations'),
  bullet('All authors must disclose COI in the manuscript'),
  bullet('ICMJE uniform disclosure form should be used'),
  bullet('Editors must recuse themselves from decisions on papers where they have COI'),

  heading3('3. Peer Review Ethics'),
  bullet('Confidentiality: Reviewers must not disclose contents of manuscripts under review'),
  bullet('Objectivity: Reviews based on scientific merit, not personal bias'),
  bullet('No use of unpublished data from reviewed manuscripts'),
  bullet('Disclose COI with the manuscript being reviewed'),
  bullet('Timely completion of review'),
  bullet('Open vs double-blind review — each journal defines its model'),

  heading3('4. Research Integrity'),
  bullet('Fabrication: Inventing data that was never collected — SCIENTIFIC FRAUD'),
  bullet('Falsification: Manipulating data, images, or results to misrepresent findings'),
  bullet('Selective reporting: Only publishing positive results (publication bias)'),
  bullet('Data manipulation: Inappropriate statistical analysis to achieve desired outcome'),
  bullet('Image manipulation: Altering photomicrographs, gels beyond acceptable processing'),
  note('FFP (Fabrication, Falsification, Plagiarism) are the three cardinal research misconducts — COPE/ICMJE/ORI (Office of Research Integrity) categorization.'),

  heading3('5. Informed Consent & Research Ethics'),
  bullet('All human research must have institutional ethics committee (IEC/IRB) approval'),
  bullet('Informed consent from all participants'),
  bullet('Clinical trials must be registered (ClinicalTrials.gov / CTRI India before first participant enrolment)'),
  bullet('Declaration of Helsinki (2013, Fortaleza revision) governs ethics in human research'),
  bullet('Animal research: 3Rs principle — Replacement, Reduction, Refinement'),

  heading3('6. Duplicate/Redundant Publication'),
  bullet('Submitting the same manuscript to two journals simultaneously — unethical (Salami slicing)'),
  bullet('Secondary publication acceptable only if primary journal is acknowledged and different audience'),
  bullet('Redundant publication wastes peer reviewers\' time and inflates publication records'),

  heading3('7. Data Sharing and Transparency'),
  bullet('Raw data should be available on request or deposited in public repositories'),
  bullet('ICMJE mandates data sharing statement in all clinical trials from 2019'),
  bullet('Replication crisis in medicine — data transparency is critical'),

  heading3('8. Retraction and Corrections'),
  bullet('Retraction: When published work contains major errors, fraud, or ethical violations'),
  bullet('Correction (Erratum): Minor errors that do not affect conclusions'),
  bullet('COPE Retraction Guidelines 2019 (updated 2022): Editors must retract when fraud/plagiarism proven'),
  bullet('Retracted papers must be clearly marked in all databases'),

  heading2('PART B: TYPES OF PLAGIARISM'),
  mkTable(
    ['Type of Plagiarism', 'Description', 'Example'],
    [
      ['Direct / Verbatim Plagiarism', 'Word-for-word copying without citation or quotes', 'Copying a paragraph from a paper and pasting directly'],
      ['Mosaic / Patchwork Plagiarism', 'Mixing phrases from multiple sources, slightly rephrased, without citation', 'Changing a few words from 3 different papers and combining'],
      ['Paraphrase Plagiarism', 'Rewriting someone\'s idea in own words without giving credit', 'Summarizing a study\'s conclusion without citing the original'],
      ['Self-Plagiarism / Auto-plagiarism', 'Reusing own previously published work without acknowledgement', 'Republishing data from thesis/earlier paper in new journal'],
      ['Idea / Concept Plagiarism', 'Stealing a novel idea, hypothesis, or original concept from others', 'Presenting a colleague\'s hypothesis as one\'s own'],
      ['Structural Plagiarism', 'Replicating the logical structure/argument of a paper even if words differ', 'Following the same analytical framework of a paper without credit'],
      ['Source / Citation Plagiarism', 'Citing a secondary source as if reading the primary source', 'Citing Smith (2010) when you only read Jones (2015) who cited Smith'],
      ['Accidental / Unintentional Plagiarism', 'Failure to cite due to ignorance of referencing rules', 'Student not knowing they needed to cite a fact'],
      ['Contract Cheating / Ghost-writing', 'Submitting work written by another person (paid service)', 'Using essay mills, ChatGPT (undisclosed) for academic submission'],
      ['Data Plagiarism', 'Using another researcher\'s raw data without permission', 'Using tables/figures from a paper without permission/citation'],
    ],
    [2500, 3500, 3400]
  ),
  note('Turnitin, iThenticate, and Unicheck are commonly used plagiarism detection software in medical journals. Acceptable similarity index: < 15–20% (varies by journal).'),

  heading2('PART C: METHODS TO AVOID PLAGIARISM'),
  mkTable(
    ['Method', 'How to Apply'],
    [
      ['Proper Citation', 'Cite every source used — primary literature, textbooks, guidelines. Use Vancouver/APA/Harvard format consistently.'],
      ['Direct Quotation with Attribution', 'When using exact words, use quotation marks AND cite the source with page number.'],
      ['Paraphrasing Correctly', 'Understand the idea, close the source, rewrite in your own words, then cite. Do not merely synonym-swap.'],
      ['Use of Reference Management Software', 'Use Mendeley, Zotero, EndNote, RefWorks — auto-generate citations and reference lists. Prevents accidental citation errors.'],
      ['Self-citation acknowledgement', 'When reusing own data/text from previous publications — cite own previous work explicitly.'],
      ['Plagiarism Detection Software (self-check)', 'Run manuscript through Turnitin/iThenticate before submission. Target <15% similarity.'],
      ['Research Note-taking practices', 'Always note source alongside notes while reading. Distinguishing original thoughts from read material prevents accidental plagiarism.'],
      ['Awareness and Training', 'Institutional workshops on research ethics, academic integrity. COPE/ICMJE guidelines should be taught in PG curriculum.'],
      ['Ethics Committee Oversight', 'All institutional research reviewed for plagiarism and ethical conduct before publication.'],
      ['Journal compliance', 'Adhere to journal\'s authorship and originality statement; sign ICMJE authorship forms.'],
    ],
    [3000, 6400]
  ),
  guideline('COPE (Committee on Publication Ethics) Best Practice Guidelines 2023 & ICMJE Recommendations 2024: All journals should have a defined plagiarism policy; editors should use plagiarism detection tools for all submissions.'),
  divider(),
);

// ─────────────────────────────────────────────────────────────────────────────
// QUESTION 5
// ─────────────────────────────────────────────────────────────────────────────
content.push(
  new Paragraph({
    children: [new TextRun({ text: 'QUESTION 5 (10 Marks)', bold: true, size: 28, color: '7B2C2C' })],
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    children: [new TextRun({ text: '(a) Describe \'Baby Friendly Hospital Initiative\'. [5 Marks]\n(b) Discuss \'Kangaroo Mother Care\'. [5 Marks]', bold: true, italics: true, size: 24, color: '1F3864' })],
    spacing: { before: 120, after: 240 },
  }),

  heading2('PART A: BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)'),

  heading3('Background'),
  para('The Baby Friendly Hospital Initiative (BFHI) is a global programme launched jointly by WHO and UNICEF in 1991 to promote, protect, and support breastfeeding. It operates in over 150 countries. In India, it is implemented under the National Health Mission (NHM) framework.'),
  guideline('WHO/UNICEF BFHI Implementation Guidance 2018 (updated 2022): All maternity facilities should be assessed against the 10 Steps to Successful Breastfeeding.'),

  heading3('The Ten Steps to Successful Breastfeeding — BFHI Core (WHO/UNICEF 2018)'),
  mkTable(
    ['Step', 'Critical Management Procedures (CMP)'],
    [
      ['Step 1a', 'Comply with the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions'],
      ['Step 1b', 'Have a written infant feeding policy — routinely communicated to all staff'],
      ['Step 2', 'Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding'],
      ['Step 3', 'Discuss the importance and management of breastfeeding with pregnant women and their families'],
      ['Step 4', 'Facilitate immediate and uninterrupted skin-to-skin contact — place babies in skin-to-skin contact with their mothers immediately following birth for at least one hour'],
      ['Step 5', 'Support mothers to initiate and maintain breastfeeding and manage common difficulties (Early Initiation of Breastfeeding — EIBF within 1 hour of birth)'],
      ['Step 6', 'Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated'],
      ['Step 7', 'Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day'],
      ['Step 8', 'Support mothers to recognize and respond to their infants\' cues for feeding (demand feeding / responsive feeding)'],
      ['Step 9', 'Counsel mothers on the use and risks of feeding bottles, teats and pacifiers (no bottles, teats, or dummies)'],
      ['Step 10', 'Coordinate discharge so that parents and their infants have timely access to ongoing support and care'],
    ],
    [1200, 8200]
  ),

  heading3('Key Definitions Under BFHI'),
  bullet('Early Initiation of Breastfeeding (EIBF): Initiation within 1 hour of birth — WHO/UNICEF/NHM target'),
  bullet('Exclusive Breastfeeding (EBF): Only breast milk (no water, juices, or other food) for the first 6 months of life'),
  bullet('Rooming-in: Mother and baby remain together 24h/day — prevents formula supplementation'),
  bullet('Demand/Responsive feeding: Baby fed whenever hungry — improves milk supply'),
  bullet('Colostrum: The "liquid gold" — first milk; immunoglobulin-rich (IgA, IgG), anti-infective, nutritionally dense; must NOT be discarded'),

  heading3('Benefits of BFHI / Breastfeeding'),
  mkTable(
    ['For Baby', 'For Mother'],
    [
      ['Reduces infant mortality (WHO: Breastfeeding prevents ~820,000 child deaths/year globally)', 'Reduces postpartum haemorrhage (oxytocin release)'],
      ['Reduces risk of diarrhoea and pneumonia (most common causes of under-5 mortality)', 'Promotes uterine involution'],
      ['Reduces risk of necrotizing enterocolitis (NEC) in preterm infants', 'Reduces risk of breast cancer (RR ~0.78) and ovarian cancer'],
      ['Improves cognitive development (IQ advantage ~3–5 points)', 'Reduces risk of type 2 diabetes mellitus'],
      ['Reduces risk of obesity, T2DM in later life', 'Promotes maternal-infant bonding'],
      ['Passive immunity via IgA — protection against infections', 'Promotes weight loss post-delivery'],
      ['Reduces SIDS (Sudden Infant Death Syndrome) risk by ~50%', 'Natural contraception (LAM — Lactational Amenorrhoea Method)'],
    ],
    [4700, 4700]
  ),

  heading3('BFHI Certification Process'),
  bullet('Hospitals apply to national BFHI authority for assessment'),
  bullet('External assessment team visits facility'),
  bullet('Interview of mothers, nurses, and administrators'),
  bullet('Direct observation of practices'),
  bullet('Must demonstrate compliance with all 10 Steps + International Code compliance'),
  bullet('Re-assessment every 3–5 years'),

  heading3('Medical Contraindications to Breastfeeding (BFHI allows exceptions)'),
  mkTable(
    ['Condition', 'Recommendation'],
    [
      ['HIV positive mother (in high-income settings)', 'Avoid breastfeeding if formula feeding safe, affordable, acceptable, feasible, sustainable (AFASS criteria) — UNAIDS/WHO'],
      ['HIV positive mother (in LMIC settings, India)', 'Exclusive breastfeeding for 6 months with maternal ART under PMTCT — WHO 2022 recommends breastfeeding with ARV cover'],
      ['Infant with Galactosaemia', 'Breastfeeding contraindicated absolutely'],
      ['Infant with PKU (Phenylketonuria)', 'Partial breastfeeding; Phe-free formula supplement'],
      ['Active untreated TB in mother', 'Defer breastfeeding until mother is non-infectious (2 weeks AKT)'],
      ['Herpes simplex lesions on breast', 'Avoid feeding from affected breast; other breast allowed'],
    ],
    [3500, 6000]
  ),
  guideline('WHO Breastfeeding Guidelines 2022: In resource-limited settings, breastfeeding with ARV therapy is recommended over formula feeding for HIV+ mothers — risk of formula feeding (diarrhoea, malnutrition) outweighs HIV transmission risk with ART coverage.'),

  heading2('PART B: KANGAROO MOTHER CARE (KMC)'),

  heading3('Definition'),
  para('Kangaroo Mother Care (KMC) is a method of care for preterm/low birth weight (LBW) neonates that involves:'),
  bullet('Continuous skin-to-skin contact (SSC) between the infant (wearing only a diaper and cap) and the caregiver (mother/father/family member) — infant is held upright, in "frog-leg" position on the chest'),
  bullet('Exclusive breastfeeding / expressed breast milk'),
  bullet('Early discharge from hospital with close follow-up'),

  heading3('Historical Background'),
  para('KMC was first described by Dr. Edgar Rey Sanabria and Dr. Hector Martinez in Bogota, Colombia in 1978 — developed due to shortage of incubators. WHO adopted it globally in 1993. The WHO published the first formal KMC guidelines in 2003, updated significantly in 2022.'),

  heading3('WHO KMC Guidelines 2022 — KEY UPDATES'),
  mkTable(
    ['Recommendation', 'WHO 2022 Evidence Grade'],
    [
      ['KMC should be initiated as soon as possible after birth (within minutes to hours) for ALL stable infants <2000g', 'Strong recommendation, high certainty'],
      ['KMC (immediate/early) reduces 28-day mortality by 25% in infants <2000g compared to conventional incubator care', 'Strong recommendation, high certainty (large RCT — WHO, NEJM 2021)'],
      ['Continuous KMC (skin-to-skin 20+ hours/day) should be the goal', 'Strong recommendation'],
      ['KMC should be provided in all health facilities (even Level III NICUs) — not just low-resource settings', 'Strong recommendation'],
      ['Both parents and family members can provide KMC', 'Strong recommendation'],
      ['KMC should continue post-discharge until infant reaches 2500g or corrected age of 40 weeks', 'Strong recommendation'],
    ],
    [5000, 4400]
  ),

  heading3('Technique of KMC'),
  mkTable(
    ['Component', 'Description'],
    [
      ['Positioning', 'Infant placed vertically (upright), chest-to-chest on mother\'s bare skin, head turned to one side in "sniffing position" — maintains airway patency'],
      ['Clothing', 'Infant: only diaper + cap + socks. Mother: open-front garment (wrap/shawl to secure infant). Father/caregiver: shirt unbuttoned'],
      ['Duration', 'Aim for ≥20 hours/day continuous SSC; all remaining time in warm cot or incubator'],
      ['Feeding', 'Breastfeed on demand; supplement with expressed breast milk (cup/tube/palatal feeder) if breastfeeding not established'],
      ['Monitoring', 'Continuous SpO2 and temperature monitoring especially when initiating; assess feeding, weight, jaundice'],
      ['Position change', 'Can be changed between parents/family members — "shared KMC"'],
    ],
    [2500, 7000]
  ),

  heading3('Benefits of KMC — Evidence-Based'),
  mkTable(
    ['Outcome', 'Evidence'],
    [
      ['Reduced 28-day neonatal mortality (≥25%)', 'WHO multi-country RCT, NEJM 2021; Sivanandan & Sankar, BMJ Global Health 2023 (PMID 37277198)'],
      ['Reduced hypothermia', 'Skin-to-skin maintains core temperature (thermo-neutral zone provided by mother\'s body)'],
      ['Improved breastfeeding rates', 'Exclusive breastfeeding significantly higher at discharge and at 1 month'],
      ['Reduced late-onset neonatal sepsis', 'Skin-to-skin contact colonises infant with mother\'s normal flora — protective against nosocomial infection'],
      ['Reduced NEC (Necrotising Enterocolitis)', 'Better gut colonisation, higher human milk intake'],
      ['Better neurodevelopmental outcomes', 'Improved brain development, cognitive scores at 1 year (Cristabal Canadas et al., IJERPH 2022, PMID 35010848)'],
      ['Reduced apnoea of prematurity', 'SSC provides respiratory regularity via chest wall vibration/proprioception'],
      ['Shorter hospital stay', 'Significant reduction in NICU duration'],
      ['Reduced physiological stress in infant', 'Lower cortisol, better HPA axis regulation (Cristabal et al., 2022)'],
      ['Maternal psychological benefits', 'Reduced maternal anxiety, depression, improved bonding, higher breastfeeding self-efficacy (Pathak et al., Bull WHO 2023, PMID 37265678)'],
    ],
    [3500, 6000]
  ),

  heading3('KMC in India — Implementation'),
  bullet('National Neonatology Forum (NNF) India recommends KMC as standard of care for all neonates <2000g'),
  bullet('KMC implemented in Special Newborn Care Units (SNCUs) and Newborn Stabilization Units (NBSUs) under NHM'),
  bullet('KMC corners / KMC chairs established in all SNCUs under RMNCH+A strategy'),
  bullet('IMNCI (Integrated Management of Neonatal and Childhood Illness) programme incorporates KMC training for ANMs, nurses'),
  bullet('India National Guidelines on KMC: Ministry of Health and Family Welfare (MoHFW) + NNF KMC Operational Guidelines 2014, revised 2022'),

  heading3('Contraindications / Precautions for KMC'),
  mkTable(
    ['Situation', 'Recommendation'],
    [
      ['Critically ill, unstable neonate on ventilator', 'Defer KMC until stabilised; modified KMC possible with careful monitoring'],
      ['Infant with major surgical conditions (gastroschisis, etc.)', 'KMC deferred — modify as per surgical team advice'],
      ['Mother with active infections (TB — open, uncontrolled)', 'Father/family member provides KMC until mother non-infectious'],
      ['Maternal exhaustion', 'Share with father/family — shared/paternal KMC encouraged by WHO 2022'],
    ],
    [3500, 6000]
  ),

  heading3('COMPARISON — Incubator vs KMC'),
  mkTable(
    ['Parameter', 'Conventional Incubator Care', 'Kangaroo Mother Care'],
    [
      ['Cost', 'High (equipment-dependent)', 'Low / zero cost'],
      ['Infection risk', 'Nosocomial infection risk (NICU flora)', 'Colonized by normal maternal flora — protective'],
      ['Mother-baby bonding', 'Impaired (separation)', 'Enhanced (continuous contact)'],
      ['Breastfeeding', 'Difficult to establish', 'Significantly better rates'],
      ['Temperature regulation', 'Incubator-dependent', 'Thermo-neutral via maternal body'],
      ['Mortality (LBW <2000g)', 'Reference', '25% reduction with KMC (WHO RCT 2021)'],
      ['Neurodevelopment', 'Standard NICU outcomes', 'Superior outcomes (stimulation of sensory pathways)'],
      ['Resource availability', 'Requires NICU', 'Can be done at all facility levels + home'],
    ],
    [2500, 3500, 3500]
  ),
  guideline('WHO Guidelines on Kangaroo Mother Care 2022: KMC should be initiated as soon as possible for ALL LBW infants (not just those without access to incubators). Continuous KMC 20+ hours/day reduces 28-day neonatal mortality by 25%.'),

  new Paragraph({
    children: [new TextRun({ text: '─── END OF QUESTIONS 1–5 ───', bold: true, size: 24, color: '1F3864' })],
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  }),

  new Paragraph({
    children: [new TextRun({ text: 'References / Key Guidelines Used:', bold: true, size: 22, color: '7B2C2C' })],
    spacing: { before: 200, after: 100 },
  }),
  bullet('ESHRE ART Guideline 2023 | ASRM Committee Opinion on Oocyte Cryopreservation 2021'),
  bullet('ESHRE-ASRM-CREWHIRL-IMS POI Guideline, Fertil Steril 2025 (PMID 39652037)'),
  bullet('RCOG Green-Top Guideline 27b: Vasa Previa 2018 | SOGC CPG 2017 | ACOG 2023'),
  bullet('Heyborne K. Obstet Gynecol 2023 (PMID 37535966) | Laiu et al. Eur J Obstet 2024 (PMID 38057179)'),
  bullet('ICMJE Recommendations 2024 | COPE Guidelines 2023'),
  bullet('WHO/UNICEF BFHI 10 Steps Guidance 2018 (updated 2022)'),
  bullet('WHO KMC Guidelines 2022 | NNF India KMC Operational Guidelines 2022'),
  bullet('Sivanandan S, Sankar MJ. BMJ Global Health 2023 (PMID 37277198)'),
  bullet('Pathak BG, Sinha B et al. Bull World Health Organ 2023 (PMID 37265678)'),
  bullet('Cristabal Canadas D et al. IJERPH 2022 (PMID 35010848)'),
);

// ─── BUILD DOCUMENT ───────────────────────────────────────────────────────────
const doc = new Document({
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mkdir -p /home/daytona/workspace/DNB-OBG-Dec22-P4 && node --version && ls /home/…

cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && npm list docx 2>/dev/null | head …

npm list -g docx 2>/dev/null | head -5; ls /usr/lib/node_modules/ 2>/dev/null; l…

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// ── TITLE ────────────────────────────────────────────────────────────────────
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// ============================================================================
// QUESTION 1
// ============================================================================
var q1 = qHeader('1', '10',
  'Discuss cryopreservation of embryo and oocyte, length of successful preservation and what influences rates of successful pregnancy outcome?');
q1.forEach(function(i){ content.push(i); });

content.push(
  h2('INTRODUCTION'),
  p('Cryopreservation is the process of cooling and storing biological material (embryos, oocytes, sperm, ovarian/testicular tissue) at ultra-low temperatures (−196°C in liquid nitrogen) to halt all metabolic activity. It is a cornerstone of modern Assisted Reproductive Technology (ART). Endorsed by ESHRE 2023, ASRM 2021, and ICMR/NMC guidelines.'),

  h2('SECTION A: EMBRYO CRYOPRESERVATION'),
  h3('1. Methods of Embryo Freezing'),
  tbl(
    ['Method', 'Principle', 'Cooling Rate', 'Post-thaw Survival', 'Current Status'],
    [
      ['Slow / Controlled Rate Freezing', 'Stepwise cooling using low concentrations of cryoprotectants; ice forms in extracellular space', '0.3 \u20132\u00b0C/min', '60\u201380%', 'Largely superseded by vitrification'],
      ['Vitrification (Gold Standard)', 'Ultra-rapid cooling using high cryoprotectant concentration \u2014 converts to glass-like state, NO ice crystal formation', '>10,000\u00b0C/min', '90\u201397%', 'GOLD STANDARD \u2014 ESHRE 2023 & ASRM 2021'],
      ['Open Carrier Vitrification', 'Direct contact with liquid nitrogen (LN2)', 'Fastest', 'Highest', 'Risk of cross-contamination; caution for infectious patients'],
      ['Closed Carrier Vitrification', 'No direct LN2 contact; sealed device', 'Slightly slower', 'Comparable', 'Preferred for infection control (HIV, HBV patients)'],
    ],
    [1900, 2400, 1500, 1800, 1900]
  ),

  h3('2. Stage of Embryo at Time of Freezing'),
  tbl(
    ['Stage', 'Day', 'Key Advantage', 'Post-thaw Survival', 'Implantation Rate'],
    [
      ['Pronuclear (2PN zygote)', 'Day 1', 'Highest cryotolerance of all stages', '85\u201390%', 'Lower than blastocyst'],
      ['Cleavage stage (4\u20138 cell)', 'Day 2\u20133', 'Earlier assessment; multiple blastomeres offer resilience', '80\u201385%', 'Moderate'],
      ['Blastocyst (PREFERRED)', 'Day 5\u20136', 'Best self-selection; highest implantation potential; inner cell mass and trophectoderm clearly visible for grading', '90\u201397%', 'Highest \u2014 35\u201350% per transfer'],
    ],
    [2200, 1000, 2500, 1800, 2000]
  ),
  gBox('ESHRE ART Guideline 2023: Blastocyst-stage vitrification is the preferred strategy for freeze-all cycles and elective frozen embryo transfer (eFET). Single blastocyst transfer (SBT) is recommended to reduce multiple pregnancies.'),

  h3('3. Cryoprotectants (CPAs)'),
  tbl(
    ['Type', 'Examples', 'Mechanism'],
    [
      ['Permeating (intracellular) CPAs', 'DMSO, Ethylene glycol (EG), Propylene glycol (PROH), Glycerol', 'Enter cells, replace intracellular water, prevent ice crystal nucleation within the cell'],
      ['Non-permeating (extracellular) CPAs', 'Sucrose, Trehalose, Raffinose', 'Increase extracellular osmolarity, draw water out of cells before freezing'],
    ],
    [2500, 3000, 4000]
  ),

  h3('4. Freeze-All Strategy'),
  bp('Freeze all embryos in a stimulation cycle and defer transfer to a subsequent cycle'),
  bp('Indications: OHSS risk, elevated progesterone on trigger day, endometrial polyp, poor endometrial response, PGT-A (preimplantation genetic testing), suboptimal endometrium'),
  bp('ESHRE 2023: Freeze-all + eFET is now a standard strategy in IVF; reduces fresh OHSS risk significantly'),

  h2('SECTION B: OOCYTE CRYOPRESERVATION'),
  h3('1. Why Oocytes Are Technically Challenging to Freeze'),
  tbl(
    ['Challenge', 'Explanation'],
    [
      ['Large cell volume', 'More intracellular water \u2192 greater risk of intracellular ice crystal formation'],
      ['Metaphase II (MII) spindle sensitivity', 'The meiotic spindle is temperature-sensitive; chilling disrupts spindle fibres, risking aneuploidy'],
      ['Zona pellucida hardening', 'CPA exposure may harden ZP \u2192 impairs sperm penetration \u2192 ICSI is preferred over standard IVF for vitrified oocytes'],
      ['High lipid content of cytoplasm', 'Contributes to chilling injury in some species; less prominent in human oocytes'],
    ],
    [2500, 7000]
  ),
  noteBox('Post-vitrification MII spindle reassembly occurs in >90% of oocytes within 3 hours of warming at 37°C (ASRM 2021). This is why a 3-hour rest period is recommended before ICSI.'),

  h3('2. Current Standard: Mature MII Oocyte Vitrification'),
  tbl(
    ['Step', 'Detail'],
    [
      ['1. Ovarian stimulation', 'Controlled ovarian stimulation (COS) with gonadotrophins \u2014 antagonist protocol preferred for fertility preservation (rapid, OHSS-sparing)'],
      ['2. Egg retrieval', 'Transvaginal ultrasound-guided oocyte retrieval 35\u201336h after hCG/GnRH-agonist trigger'],
      ['3. Oocyte processing', 'Denudation (removal of cumulus cells); identification of mature MII oocytes (1st polar body visible)'],
      ['4. Vitrification', 'Loading onto cryodevice (Cryotop, Cryoleaf, etc.) with equilibration in CPA solution; plunge into LN2'],
      ['5. Storage', 'Stored in LN2 vapour phase or liquid phase at \u2212196\u00b0C'],
      ['6. Warming', 'Rapid warming; dilution of CPA; 3h rest period before ICSI'],
      ['7. Fertilization', 'ICSI preferred (not standard IVF) to overcome ZP hardening'],
    ],
    [1500, 8000]
  ),

  h3('3. Indications for Oocyte Cryopreservation'),
  tbl(
    ['Indication Category', 'Specific Examples'],
    [
      ['Oncofertility', 'Breast cancer, cervical cancer, leukaemia before chemotherapy/radiotherapy; most common indication in young women'],
      ['Elective (Social) Fertility Preservation', 'Career, relationship status, personal reasons \u2014 \u201cSocial egg freezing\u201d'],
      ['Diminished Ovarian Reserve', 'Premature ovarian insufficiency (POI), BRCA mutation carriers, Turner syndrome mosaics'],
      ['No partner / religious objection to embryo freezing', 'Cannot create embryo at time of retrieval; Islamic/Catholic ethics permitting oocyte but not embryo storage'],
      ['Donor egg banking', 'Vitrified donor oocyte banks; eliminates synchronisation requirement between donor and recipient'],
      ['IVF emergency', 'Absent/no usable sperm on retrieval day; oocytes vitrified while sperm situation resolved'],
    ],
    [2800, 6700]
  ),
  gBox('ASRM Committee Opinion 2021 (Fertil Steril): Oocyte cryopreservation is no longer experimental and should be offered to all eligible women facing gonadotoxic therapy. Informed counselling about realistic success rates is mandatory.'),
  gBox('ESHRE Guideline on Fertility Preservation 2020 (updated 2023): Vitrification of mature oocytes is the recommended standard. Ovarian tissue cryopreservation (OTC) remains an option particularly when COS is not feasible (prepubertal girls, hormone-sensitive cancers, time constraints).'),

  h2('SECTION C: LENGTH OF SUCCESSFUL PRESERVATION'),
  tbl(
    ['Material', 'Reported Maximum Successful Storage', 'Key Evidence / Clinical Data'],
    [
      ['Embryos', 'Up to 20+ years; live births reported from embryos stored for >19 years', 'Riggs et al., Fertil Steril 2010: Healthy twins born from embryos stored 19 years. Theoretically indefinite at \u2212196\u00b0C.'],
      ['Mature oocytes (MII)', 'Up to 10+ years with no significant loss of competence demonstrated', 'Cobo et al., Fertil Steril 2020: No significant decrease in oocyte competence up to 5 years; beyond 5y data emerging with similar results.'],
      ['Ovarian tissue', 'Up to 10+ years; successful orthotopic transplantation and live births reported', 'Demeestere et al., Hum Reprod 2015; ESO/ESHRE guidelines 2022'],
      ['Sperm', 'Theoretically indefinite; live births from sperm stored 21+ years', 'BFS (British Fertility Society) Guidelines 2019'],
    ],
    [1800, 3500, 4200]
  ),
  p('Scientific Principle: At −196°C, ALL biological and metabolic processes are halted. Brownian motion essentially ceases. Theoretically, cryopreserved material does not deteriorate over time in storage. The critical determinant is quality of material AT THE TIME OF FREEZING, not duration of storage.'),
  noteBox('LEGAL LIMITS (Country-specific): UK (HFEA): Embryos stored up to 10 years, extendable to 55 years for medical necessity. India (ART Regulation Act 2021 / ICMR): Embryos stored up to 5 years on consent, extendable. USA: No federal legal limit; centres set their own policies.'),

  h2('SECTION D: FACTORS INFLUENCING PREGNANCY OUTCOME AFTER CRYOPRESERVATION'),
  tbl(
    ['Factor', 'Direction of Effect', 'Clinical Details'],
    [
      ['Age at time of freezing', '\u2B06\uFE0F MOST IMPORTANT FACTOR', '<35y: LBR 40\u201350% per transfer; 35\u201337y: 30\u201340%; 38\u201340y: 20\u201330%; >40y: <15% per transfer (SART 2022, ESHRE 2023)'],
      ['Vitrification vs Slow Freeze', '\u2B06\uFE0F Vitrification far superior', 'Vitrification gives 10\u201315% higher post-thaw survival and 5\u201310% higher clinical pregnancy rates per transfer'],
      ['Stage of embryo at freezing', '\u2B06\uFE0F Blastocyst > cleavage > PN', 'Blastocyst FET: 35\u201350% CPR per transfer. Cleavage: 20\u201330%. Self-selection at blastocyst stage removes chromosomally abnormal embryos'],
      ['Embryo morphological quality', '\u2B06\uFE0F Gardner blastocyst grading', 'AA/AB grade blastocysts: highest implantation. BC/CB: lower. Cryosurvival itself is >95% regardless of grade with vitrification.'],
      ['Number of oocytes vitrified', '\u2B06\uFE0F For oocyte banking', '8\u201312 MII oocytes recommended for a reasonable cumulative LBR in women <35y (\u224865\u201370% cumulative). Fewer oocytes = proportionally lower chances.'],
      ['Endometrial preparation for FET', 'CRITICAL', 'Natural cycle (NC-FET) vs Artificial/HRT cycle (AC-FET) vs Modified natural cycle. NC-FET preferred for ovulatory women \u2014 lower rates of hypertensive disorders, LGA neonates (ESHRE 2023 evidence).'],
      ['Number of embryos transferred', '\u2B06\uFE0F Single > double for safety', 'Single embryo transfer (SET) is ESHRE/ASRM standard. Double transfer increases twins risk dramatically without proportionate benefit in good-prognosis patients.'],
      ['Body mass index (BMI)', '\u2B07\uFE0F Higher BMI = worse outcomes', 'BMI >30: implantation rates reduced 10\u201315%; higher miscarriage risk; impaired endometrial receptivity'],
      ['Smoking', '\u2B07\uFE0F Major negative effect', 'Active smoking reduces success rates by 30\u201350%; damages oocyte DNA and endometrial receptivity'],
      ['Male factor (sperm quality)', 'Moderate', 'Severe OAT or high DNA fragmentation can reduce fertilization rates post-ICSI even with excellent oocytes'],
      ['Cause of infertility', 'Moderate', 'Endometriosis and uterine pathology reduce implantation. Tubal factor and male factor have better FET outcomes.'],
      ['PGT-A (Preimplantation Genetic Testing)', '\u2B06\uFE0F In selected populations', 'PGT-A of blastocysts before FET: reduces miscarriage, improves per-transfer LBR in women >37y and recurrent implantation failure \u2014 ESHRE PGT Consortium 2023'],
      ['Lab quality & CLSI/ESHRE certification', '\u2B06\uFE0F Critical', 'Temperature, humidity control, VOC-free air; embryologist expertise; cryodevice quality all significantly impact outcomes'],
    ],
    [2800, 2200, 4500]
  ),

  h2('SECTION E: FET PROTOCOL OPTIONS'),
  tbl(
    ['Protocol', 'Method', 'Indication', 'Key Evidence'],
    [
      ['Natural Cycle (NC-FET) \u2714 PREFERRED', 'Monitor natural ovulation; transfer blastocyst 5 days after LH surge / hCG trigger; luteal support with progesterone', 'Ovulatory women with regular cycles', 'ESHRE 2023: Lower risk of HDP and LGA neonates vs AC-FET. Cochrane 2022: No difference in LBR but better obstetric safety.'],
      ['Modified Natural Cycle (mNC-FET)', 'Natural monitoring + hCG trigger; more predictable timing', 'Ovulatory women needing scheduling', 'Acceptable alternative to pure NC-FET'],
      ['Artificial / HRT Cycle (AC-FET)', 'Oral/transdermal estradiol to grow endometrium (target >7mm trilaminar); vaginal/IM progesterone for luteal support; no LH monitoring needed', 'Anovulatory women (PCOS, POI), donor egg cycles, when scheduling is essential', 'Flexible scheduling; slightly higher HDP risk vs NC-FET (Cochrane 2022)'],
    ],
    [2200, 2500, 2200, 2600]
  ),

  h2('KEY OUTCOME STATISTICS \u2014 QUICK REFERENCE'),
  tbl(
    ['Scenario', 'Live Birth Rate (LBR) Per Transfer'],
    [
      ['Vitrified blastocyst FET, woman <35y', '40\u201350% (SART 2022 national data)'],
      ['Vitrified blastocyst FET, woman 35\u201337y', '30\u201340%'],
      ['Vitrified blastocyst FET, woman 38\u201340y', '20\u201330%'],
      ['Vitrified blastocyst FET, woman >40y', '<15%'],
      ['Vitrified oocyte, woman <35y (\u22658 oocytes)', '35\u201345% per transfer; cumulative \u224865% with 10 oocytes'],
      ['Cumulative LBR: IVF freeze-all + multiple FETs', '70\u201380% overall (all age groups combined)'],
    ],
    [5000, 4500]
  ),
  noteBox('Neonatal Safety: Meta-analyses and large cohort studies show NO increased risk of major congenital anomalies in FET vs fresh transfer children. Slight increase in LGA (large for gestational age) seen with AC-FET — under investigation (ESHRE 2023).'),
  gBox('Key Guidelines: ESHRE ART Guideline 2023 | ASRM Committee Opinion on Oocyte Cryopreservation 2021 | ESHRE Fertility Preservation Guideline 2023 | ICMR/ART Act India 2021 | SART Annual Report 2022'),
  divider()
);

// ============================================================================
// QUESTION 2
// ============================================================================
var q2 = qHeader('2', '10',
  '(a) Describe criteria for diagnosis of POI. [2 Marks]\n(b) Discuss evaluation and management of POI. [8 Marks]');
q2.forEach(function(i){ content.push(i); });

content.push(
  h2('PART A: DIAGNOSTIC CRITERIA OF PREMATURE OVARIAN INSUFFICIENCY (POI)'),
  gBox('Based on: ESHRE-ASRM-CREWHIRL-IMS Evidence-Based Guideline on POI, Fertil Steril 2025 (PMID 39652037) | ESHRE POI Guideline 2016 | British Menopause Society 2024'),

  h3('Definition'),
  p('Premature Ovarian Insufficiency (POI) is defined as loss of normal ovarian function before the age of 40 years. It is a clinical syndrome characterised by menstrual disturbance and elevated gonadotrophins resulting from reduced follicular activity. It is NOT an abrupt permanent cessation of ovarian function — intermittent ovarian activity persists in up to 50% of women.'),
  noteBox('POI replaces the older terms "Premature Ovarian Failure (POF)" and "Premature Menopause" — ESHRE recommendation — because "failure" implies permanent and total cessation, which is not accurate in all cases.'),

  h3('Diagnostic Criteria (ESHRE-ASRM 2025 Joint Guideline)'),
  tbl(
    ['Criterion', 'Threshold', 'Notes'],
    [
      ['Age', '< 40 years', 'Diagnosis cannot be made at or after age 40'],
      ['Menstrual irregularity', 'Oligomenorrhoea or amenorrhoea for \u2265 4 months', 'Either primary or secondary amenorrhoea; irregular cycles also qualify'],
      ['FSH (most important biochemical marker)', '> 25 IU/L on TWO separate occasions, \u2265 4 weeks apart', 'ESHRE 2023/2025 uses FSH >25 IU/L (older texts used >40 IU/L). Two measurements required to avoid false-positives.'],
      ['Estradiol (E2)', 'Low / menopausal level (usually <50 pmol/L or <73 pg/mL)', 'Supportive but not required for diagnosis. Fluctuates.'],
      ['AMH (Anti-Mullerian Hormone)', 'Very low or undetectable (<0.5 ng/mL or <3.6 pmol/L typically)', 'Reflects severely depleted follicular pool. Supportive evidence; not sufficient alone for diagnosis.'],
    ],
    [2500, 2800, 4200]
  ),
  noteBox('The diagnosis requires ALL three: age <40y + ≥4 months menstrual irregularity + FSH >25 IU/L on TWO occasions ≥4 weeks apart. AMH and E2 are supportive, not diagnostic.'),

  h2('PART B: EVALUATION OF POI'),
  h3('A. History'),
  bp('Age of onset, duration, nature of menstrual irregularity (primary vs secondary)'),
  bp('Symptoms of estrogen deficiency: hot flushes, night sweats, vaginal dryness, dyspareunia, mood changes, sleep disturbance, cognitive changes, low libido'),
  bp('Family history of POI, fragile X syndrome, Turner syndrome, early menopause (<40y)'),
  bp('Personal history of autoimmune diseases: thyroid disease, T1DM, Addison\'s disease, rheumatoid arthritis, SLE, vitiligo'),
  bp('History of gonadotoxic treatment: chemotherapy (alkylating agents most toxic), pelvic radiotherapy, ovarian surgery (cystectomy, oophorectomy)'),
  bp('Desire for fertility, current contraception'),
  bp('Psychosocial impact: relationship concerns, depression, anxiety'),

  h3('B. Investigations — Comprehensive Evaluation'),
  tbl(
    ['Investigation', 'Purpose', 'Expected Finding / Action'],
    [
      ['FSH (\u00d72, \u22654 weeks apart)', 'Confirm diagnosis', '>25 IU/L on both occasions'],
      ['LH', 'Supportive', 'Elevated; LH:FSH ratio <1 (unlike PCOS where LH>FSH)'],
      ['Estradiol (E2)', 'Assess estrogen status', 'Low (<50 pmol/L); may fluctuate'],
      ['AMH', 'Assess follicular reserve', 'Very low or undetectable'],
      ['Prolactin', 'Exclude hyperprolactinaemia', 'Normal in POI; elevated suggests pituitary cause'],
      ['TSH, Free T4', 'Screen for thyroid disease (common comorbidity)', '~27% of POI patients have thyroid autoimmunity'],
      ['Fasting glucose / HbA1c', 'Screen for autoimmune T1DM', 'Especially if anti-adrenal Ab positive'],
      ['21-Hydroxylase antibodies (anti-adrenal Ab)', 'Screen for subclinical Addison\'s disease', '~3% of spontaneous POI; if positive \u2192 refer endocrinology; annual synacthen test'],
      ['Anti-TPO antibodies', 'Screen for autoimmune thyroiditis', 'High prevalence in POI'],
      ['Karyotype (recommended all \u226435 years)', 'Detect Turner syndrome (45,X; mosaics 45X/46XX), structural X abnormalities (deletions, translocations)', 'Mandatory in young patients; Turner mosaics may present with partial/intermittent ovarian function'],
      ['FMR1 premutation testing (Fragile X PCR)', 'Fragile X premutation (55\u2013200 CGG repeats) is most common known genetic cause of spontaneous POI (~6%)', 'ESHRE 2023: Offer to ALL women with spontaneous POI regardless of family history. Genetic counselling implications for family members.'],
      ['DEXA scan (Bone Mineral Density)', 'Baseline BMD; quantify osteoporosis risk', 'Often low at diagnosis; Z-score used (age-matched)'],
      ['Pelvic ultrasound (TVUS)', 'Antral follicle count, ovarian volume, endometrial thickness, exclude other pathology', 'Typically small ovaries, very low AFC; occasional residual follicles in intermittent POI'],
      ['Echocardiogram + Cardiac MRI (if Turner syndrome)', 'Bicuspid aortic valve, aortic coarctation, aortic root dilation', 'Found in ~30\u201350% of Turner syndrome patients; life-threatening if missed'],
      ['Renal ultrasound (if Turner syndrome)', 'Horseshoe kidney, duplex collecting system', 'Found in ~30% of Turner syndrome'],
    ],
    [2800, 2500, 4200]
  ),
  gBox('ESHRE 2023: ALL women with spontaneous POI should be offered karyotyping AND FMR1 premutation testing. Anti-adrenal antibody testing (21-hydroxylase Ab) should be offered to detect subclinical autoimmune adrenal insufficiency (risk ~3%). Annual assessment for Addison\'s if antibodies positive.'),

  h2('PART B: MANAGEMENT OF POI'),
  h3('Overview of Management Domains'),
  tbl(
    ['Domain', 'Key Intervention'],
    [
      ['1. Psychological support', 'Counselling, peer support, address grief, identity, sexual health concerns'],
      ['2. Hormone Replacement Therapy (HRT)', 'CORNERSTONE — immediate initiation; continue until age 51'],
      ['3. Fertility management', 'Donor oocyte IVF (best option); spontaneous conception possible (~5\u201310%)'],
      ['4. Bone health', 'DEXA baseline, calcium, vitamin D, weight-bearing exercise'],
      ['5. Cardiovascular health', 'HRT is cardioprotective; CV risk factor management'],
      ['6. Sexual health', 'Vaginal estrogen for GSM; lubricants; psychosexual counselling'],
      ['7. Monitoring (autoimmune comorbidities)', 'Annual TSH, adrenal function (if Ab+), glucose'],
      ['8. Turner-specific care', 'Cardiology, nephrology, endocrinology, audiometry, ophthalmology'],
    ],
    [2800, 6700]
  ),

  h3('1. Psychological Support'),
  bp('POI is a profound life event — affects identity, femininity, relationships, reproductive plans'),
  bp('Offer immediate psychological counselling at time of diagnosis'),
  bp('Group therapy / peer support groups (e.g., Daisy Network UK; POI Foundation India)'),
  bp('Address grief reaction (loss of fertility potential)'),
  bp('Discuss sexual health concerns openly — do not wait for patient to raise it'),
  bp('Partners should be included in counselling sessions where appropriate'),

  h3('2. Hormone Replacement Therapy (HRT) \u2014 CORNERSTONE'),
  tbl(
    ['Aspect', 'ESHRE-ASRM 2025 Recommendation'],
    [
      ['Indication', 'ALL women with POI (unless absolute contraindication) \u2014 for vasomotor symptoms, bone protection, cardiovascular protection, genitourinary health, cognitive health, sexual function and quality of life'],
      ['Timing', 'Start as soon as diagnosis is confirmed \u2014 delay causes harm (bone loss, cardiovascular risk)'],
      ['Duration', 'Continue until average age of natural menopause (50\u201351 years); do NOT stop at arbitrary time-point earlier'],
      ['Preferred route', 'TRANSDERMAL estrogen (patch 50\u2013100mcg; gel 2\u20134 pumps/day) \u2014 avoids first-pass hepatic metabolism; better thrombotic safety than oral estrogen'],
      ['Estrogen dose', 'Higher than standard HRT: typically 100mcg patch or equivalent \u2014 physiologic replacement, not pharmacologic dose'],
      ['Progestogen (uterus intact)', 'Micronized progesterone (Utrogestan) 200mg days 1\u201312 of month (cyclic) preferred \u2014 best safety profile for breast/CV. Alternative: dydrogesterone 10mg cyclic'],
      ['If uterus absent', 'Estrogen-only therapy'],
      ['COCP as alternative', 'Acceptable for young women needing contraception; however transdermal E+P preferred for bone/CV protection and more physiologic. COCP may suppress residual ovarian activity.'],
      ['VTE risk', 'Oral estrogen increases VTE risk; transdermal estrogen does NOT increase VTE risk \u2014 preferred in women with risk factors'],
      ['Breast cancer risk', 'HRT in POI up to age 51 does NOT increase breast cancer risk above baseline \u2014 ESHRE 2023. This is fundamentally different from HRT use after natural menopause.'],
    ],
    [2500, 7000]
  ),
  gBox('CRITICAL DISTINCTION (ESHRE-ASRM 2025): HRT in POI is REPLACEMENT of deficient hormones, not supplementation above physiologic levels. The concerns about breast cancer and CVD risk with HRT in naturally menopausal women DO NOT apply to women with POI receiving physiologic replacement until age 51.'),

  h3('3. Fertility Management'),
  tbl(
    ['Option', 'Success Rate', 'Recommendation'],
    [
      ['Spontaneous conception', '5\u201310% lifetime (intermittent ovarian activity)', 'Counsel that spontaneous pregnancy IS possible; if pregnancy not desired, reliable contraception MUST be used'],
      ['IVF with own eggs (controlled ovarian stimulation)', 'Very poor response; generally not recommended as routine', 'Only attempt if residual antral follicles present on USS; very low success rate'],
      ['Oocyte/Embryo Donation IVF (OD-IVF)', 'Cumulative LBR ~50\u201360% per cycle; excellent outcomes', 'BEST fertility option for POI \u2014 ESHRE recommends as primary treatment. FET cycles with donor embryos. Legal/ethical/cultural factors to discuss.'],
      ['Ovarian tissue transplantation', 'Experimental; reserved for cancer survivors', 'Not routine for spontaneous POI'],
      ['Adoption', 'N/A', 'Explore as an option; requires social/legal counselling'],
    ],
    [2500, 2300, 4700]
  ),

  h3('4. Bone Health'),
  bp('DEXA scan at diagnosis; repeat every 2\u20135 years depending on results and HRT compliance'),
  bp('Calcium: 1000\u20131200 mg/day (dietary sources preferred; supplement remainder)'),
  bp('Vitamin D: 800\u20131000 IU/day; target serum 25(OH)D >50 nmol/L'),
  bp('HRT is the PRIMARY bone protective treatment in POI'),
  bp('Bisphosphonates (alendronate, risedronate) only if HRT contraindicated/refused AND confirmed osteoporosis on DEXA'),
  bp('Encourage weight-bearing exercise (walking, resistance training, dancing)'),
  bp('Avoid smoking and excessive alcohol (both accelerate bone loss)'),

  h3('5. Cardiovascular Health'),
  bp('Premature estrogen deficiency doubles lifetime CVD risk'),
  bp('HRT until age 51 is CARDIOPROTECTIVE in POI (unlike post-natural-menopause HRT)'),
  bp('Annual BP monitoring; lipid profile every 2\u20133 years; fasting glucose annually'),
  bp('Promote healthy lifestyle: smoking cessation, exercise, weight management, low-salt diet'),

  h3('6. Sexual Health \u2014 Genitourinary Syndrome of Menopause (GSM)'),
  bp('GSM: vaginal dryness, dyspareunia, vulval soreness, recurrent UTI, urgency'),
  bp('Local vaginal estrogen (Estriol cream/pessary, Vagifem, Estring) \u2014 safe to use ALONGSIDE systemic HRT'),
  bp('Non-hormonal vaginal moisturisers (Replens, Yes) and lubricants (Yes WB, Sylk)'),
  bp('Pelvic floor physiotherapy for dyspareunia'),
  bp('Psychosexual counselling; address low libido (consider transdermal testosterone off-label in selected women \u2014 BMS 2024)'),

  h3('7. Monitoring of Autoimmune Comorbidities'),
  tbl(
    ['Comorbidity', 'Monitoring Schedule'],
    [
      ['Autoimmune thyroid disease', 'Annual TSH; supplement if hypothyroid; monitor for Hashimoto\'s thyroiditis'],
      ['Autoimmune adrenal insufficiency (if 21-OH Ab positive)', 'Annual morning cortisol; consider short Synacthen test (SST) annually; EMERGENCY ACTION PLAN card for patient (adrenal crisis risk)'],
      ['Autoimmune T1DM', 'Annual fasting glucose and HbA1c if at risk'],
    ],
    [3000, 6500]
  ),

  h3('8. Turner Syndrome \u2014 Specific Management'),
  tbl(
    ['System', 'Action'],
    [
      ['Cardiac', 'Echocardiogram at diagnosis; Cardiac MRI every 5\u201310 years (bicuspid AV, aortic coarctation, aortic root dilation)'],
      ['Renal', 'Renal ultrasound at diagnosis'],
      ['Audiology', 'Annual audiometry (sensorineural hearing loss in ~50%)'],
      ['Ophthalmology', 'Ptosis, strabismus, amblyopia assessment'],
      ['Endocrine', 'Growth hormone therapy in childhood; thyroid monitoring; insulin resistance'],
      ['Reproductive', 'Fertility counselling early; majority require donor egg IVF; some mosaics may have residual ovarian function'],
    ],
    [2000, 7500]
  ),

  h2('MANAGEMENT FLOWCHART \u2014 POI'),
  tbl(
    ['Step', 'Action'],
    [
      ['Step 1', 'Confirm diagnosis: FSH >25 IU/L \u00d72 (\u22654 weeks apart) + \u22654 months menstrual irregularity + age <40y'],
      ['Step 2', 'Investigations: Karyotype, FMR1 test, anti-adrenal Ab, TPO-Ab, TSH, DEXA, TVUS, E2, AMH, prolactin'],
      ['Step 3', 'Break diagnosis gently; offer immediate psychological counselling and peer support referral'],
      ['Step 4', 'Start HRT IMMEDIATELY: Transdermal estrogen (100mcg patch or 2\u20134 pumps gel) + cyclic micronized progesterone 200mg days 1\u201312 (if uterus intact)'],
      ['Step 5', 'Bone health: DEXA + calcium 1000\u20131200mg/day + Vit D 800\u20131000IU/day + weight-bearing exercise'],
      ['Step 6', 'Fertility counselling: Donor egg IVF is the best option; spontaneous pregnancy possible in ~5\u201310%'],
      ['Step 7', 'Sexual health: Local vaginal estrogen if GSM; lubricants; psychosexual counselling'],
      ['Step 8', 'Annual follow-up: TSH, BP, lipids, glucose, bone health, psychological wellbeing'],
      ['Step 9', 'Continue HRT until age 51 \u2014 NEVER stop prematurely without compelling reason'],
      ['Step 10', 'Turner-specific: Cardiac MRI, renal USS, audiometry, endocrinology referral'],
    ],
    [1000, 8500]
  ),
  gBox('Key Guideline: ESHRE-ASRM-CREWHIRL-IMS Evidence-Based Guideline on POI, Fertil Steril 2025 (PMID 39652037) | British Menopause Society Position Statement on POI 2024 | European Society of Endocrinology CPG on Menopause 2025 (PMID 41082911)'),
  divider()
);

// ============================================================================
// QUESTION 3
// ============================================================================
var q3 = qHeader('3', '10',
  '(a) Write a note on role of Umbilical Coiling Index and its significance. [3 Marks]\n(b) Discuss types of cord insertion. [2 Marks]\n(c) Discuss diagnosis and management of vasa previa. [5 Marks]');
q3.forEach(function(i){ content.push(i); });

content.push(
  h2('PART A: UMBILICAL COILING INDEX (UCI) AND ITS SIGNIFICANCE'),

  h3('Definition'),
  p('The Umbilical Coiling Index (UCI) is a quantitative measure of the helical coiling pattern of the umbilical cord vessels. It is expressed as:'),
  new Paragraph({
    children: [new TextRun({ text: 'UCI  =  Total number of complete coils of umbilical cord  \u00F7  Total length of cord (in cm)', bold: true, size: 24, color: '1F3864', font: 'Calibri' })],
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  bp('Normal UCI range: 0.17 \u2013 0.24 coils/cm (approximately 1 coil per 5 cm of cord)'),
  bp('Average cord length at term: ~55\u201360 cm with approximately 11 coils'),
  bp('UCI is most accurately measured on the delivered cord postnatally; antenatal estimation is possible via ultrasound'),

  h3('Classification of UCI'),
  tbl(
    ['Category', 'UCI Value', 'Percentile', 'Description'],
    [
      ['Hypocoiled / Non-coiled', '< 0.10 coils/cm', '< 10th percentile', 'Insufficient helical coiling; cord may be straight or loosely coiled'],
      ['Normocoiled', '0.10 \u2013 0.30 coils/cm', '10th \u2013 90th percentile', 'Normal coiling pattern; associated with normal perinatal outcomes'],
      ['Hypercoiled', '> 0.30 coils/cm', '> 90th percentile', 'Excessively tightly coiled cord; may impede blood flow'],
    ],
    [2000, 2000, 2000, 3500]
  ),

  h3('Antenatal Measurement of UCI'),
  bp('Grey-scale ultrasound: Identify cross-sections of cord in longitudinal plane; count coils per measured length'),
  bp('Color Doppler: Count color alternations in a defined segment (red\u2192blue\u2192red = one complete coil). More accurate than grey-scale alone.'),
  bp('3D Power Doppler: Provides spiral reconstruction; most accurate antenatal tool but not routinely available'),
  bp('Measured segment: Count coils in a 9 cm segment and divide by 9 to get UCI per cm'),
  noteBox('Antenatal UCI estimation has significant intra- and inter-observer variability. It is most useful when integrated with other fetal surveillance parameters (biophysical profile, Doppler studies, CTG) rather than used in isolation.'),

  h3('Significance of Abnormal UCI'),
  tbl(
    ['UCI Type', 'Associated Clinical Risks', 'Mechanism'],
    [
      ['Hypocoiled cord\n(UCI < 0.10)', '- Fetal heart rate abnormalities (late decelerations, prolonged decelerations)\n- Fetal distress in labour\n- Intrauterine fetal demise (IUFD)\n- Preterm birth\n- Cord prolapse (lax cord occupies more space)\n- Meconium-stained amniotic fluid\n- Low Apgar scores\n- Increased caesarean section for fetal distress', 'Under-coiling may indicate abnormal cord development; less mechanical protection against compression; possibly associated with fetal neuromuscular dysfunction (fetal movement drives coiling in utero)'],
      ['Hypercoiled cord\n(UCI > 0.30)', '- Fetal growth restriction (FGR)\n- Fetal hypoxia / acidaemia\n- Meconium aspiration syndrome\n- True knot formation\n- Fetal/perinatal demise\n- Oligohydramnios\n- Umbilical venous thrombosis\n- Higher rate of caesarean for non-reassuring fetal status', 'Tight coiling impedes blood flow (venous > arterial); increases intravascular resistance; reduces oxygen delivery to fetus'],
      ['Normocoiled cord\n(UCI 0.10\u20130.30)', 'Generally normal perinatal outcomes', 'Optimal coiling protects cord from external compression while maintaining vascular flow'],
    ],
    [2000, 3500, 4000]
  ),
  noteBox('UCI is a gross pathological marker — it should be used as part of a holistic assessment alongside CTG, Doppler studies, biophysical profile, and clinical context. It is NOT yet incorporated into routine antenatal care guidelines as a primary screening tool.'),

  h3('Clinical Implications / Management'),
  bp('Abnormal UCI detected antenatally warrants increased fetal surveillance: serial growth scans, umbilical artery Doppler, BPP'),
  bp('Hypocoiled cord: consider earlier or more frequent NST/CTG; low threshold for induction/delivery if biophysical profile deteriorates'),
  bp('Hypercoiled cord: monitor for FGR, consider serial Doppler; postnatal histopathological examination of cord recommended'),
  bp('Postnatal cord histopathology: Wharton\'s jelly consistency, vascular thrombosis, inflammation, single umbilical artery should all be recorded in abnormal UCI cases'),

  h2('PART B: TYPES OF CORD INSERTION'),
  tbl(
    ['Type', 'Description', 'Incidence', 'Risk / Significance'],
    [
      ['Central Insertion\n(Normal)', 'Cord inserts near the geometric centre of the placenta; vessels diverge from insertion point within the placental substance protected by Wharton\'s jelly', '>70\u201375%', 'Normal; minimal risk'],
      ['Eccentric / Paracentral Insertion', 'Cord inserts off-centre but still within the placental disc; vessels protected by Wharton\'s jelly within the placenta', '~15\u201320%', 'Minor variation; clinically insignificant in isolation'],
      ['Marginal Insertion\n(Battledore Placenta)', 'Cord inserts at the edge / margin of the placenta; vessels still have some Wharton\'s jelly protection', '~7%', 'Higher risk of fetal distress (cord compression at edge), preterm labour, low birth weight; increased risk of 2nd/3rd trimester bleeding'],
      ['Velamentous Cord Insertion\n(HIGHEST RISK)', 'Umbilical vessels separate from cord BEFORE reaching the placenta and travel unsupported through the fetal membranes (Wharton\'s jelly absent over this segment)', '1\u20132% singletons;\n~10% twins (MCDA);\n~15% triplets', 'HIGH RISK: vessels unprotected by Wharton\'s jelly \u2014 susceptible to compression, tearing, rupture; main precursor of VASA PREVIA; associated with FGR, IUFD, fetal haemorrhage; requires TVUS screening for vasa previa'],
      ['Furcate Insertion', 'Umbilical vessels fan out and divide before reaching the placental surface, with premature loss of Wharton\'s jelly a short distance from the placental edge', 'Rare (<0.1%)', 'Risk of vessel compression, torsion, thrombosis; fetal compromise'],
    ],
    [2000, 2800, 1500, 3200]
  ),
  gBox('ACOG Practice Bulletin No. 183 (2018, reaffirmed 2023) & ISUOG Practice Guidelines 2020: Cord insertion site should be documented at the routine anomaly scan (18\u201322 weeks). When velamentous insertion is identified, dedicated TVUS + Color Doppler for vasa previa is mandatory.'),
  noteBox('In IVF-conceived pregnancies, velamentous insertion is 2–4× more common than in naturally conceived pregnancies — reason for recommendation to assess cord insertion in all IVF pregnancies. In MCDA twins, velamentous insertion occurs in up to 10–15% and increases risk of TTTS.'),

  h2('PART C: VASA PREVIA \u2014 DIAGNOSIS AND MANAGEMENT'),
  h3('Definition'),
  p('Vasa previa is a condition in which fetal blood vessels — originating from a velamentous cord insertion or from vessels connecting a succenturiate (accessory) placental lobe — run through the fetal membranes over or within 2 cm of the internal cervical os, unsupported by placental tissue or Wharton\'s jelly.'),
  p('These unprotected fetal vessels are at grave risk of rupture — either spontaneously, at membrane rupture (spontaneous or artificial), or during labour — leading to fetal exsanguination.'),

  h3('Types of Vasa Previa'),
  tbl(
    ['Type', 'Description', 'Risk'],
    [
      ['Type I (Velamentous Insertion)', 'Unprotected fetal vessels from velamentous cord insertion travel across or near the internal os within the membranes', 'Rupture at membrane rupture \u2192 rapid fetal exsanguination'],
      ['Type II (Succenturiate Lobe)', 'Vessels connecting the main placenta to an accessory (succenturiate) lobe cross the lower uterine segment over the internal os', 'Same catastrophic risk as Type I'],
    ],
    [1500, 5500, 2500]
  ),

  h3('Risk Factors for Vasa Previa'),
  tbl(
    ['Risk Factor', 'Relative Importance'],
    [
      ['Velamentous cord insertion', 'PRIMARY risk factor'],
      ['Low-lying placenta or placenta previa in early pregnancy (even if resolved by term)', 'Important \u2014 vessels may remain low even after placental migration'],
      ['Succenturiate (accessory) placental lobe', 'Type II vasa previa'],
      ['Bilobed placenta', 'Vessels between lobes may cross os'],
      ['IVF-conceived pregnancy', '2\u20134\u00d7 higher risk due to higher rate of velamentous insertion'],
      ['Multiple pregnancy (twins \u2014 especially MCDA)', 'Higher rate of velamentous insertion'],
      ['Multiparity and prior uterine surgery', 'Moderate risk factor'],
    ],
    [4000, 5500]
  ),

  h3('DIAGNOSIS OF VASA PREVIA'),
  h3('A. Antenatal Ultrasound Diagnosis'),
  tbl(
    ['Modality', 'Technique', 'Finding'],
    [
      ['Transvaginal Ultrasound (TVUS) \u2014 GOLD STANDARD', 'Sagittal plane; empty bladder; assess lower uterine segment and internal os', 'Echogenic linear/tubular structure (vessel) seen over or within 2cm of internal os on grey-scale'],
      ['Color Doppler TVUS', 'Applied over the echogenic structure near os', 'Confirms fetal blood flow (pulsatile or sinusoidal waveform) within the structure \u2014 DIAGNOSTIC'],
      ['Pulsed Wave Doppler', 'Sample within the identified vessel', 'Fetal heart rate waveform confirming fetal origin of the vessel (not maternal)'],
      ['3D USS / 3D Power Doppler', 'Volumetric assessment', 'Best delineation of vessel course relative to os; aids surgical planning; not universally available'],
      ['MRI (rarely needed)', 'When USS inconclusive', 'Can confirm vasa previa and vessel anatomy in complex placentation'],
    ],
    [2500, 2500, 4500]
  ),
  gBox('SOGC Clinical Practice Guideline 2017 | RCOG Green-Top Guideline 27b 2018 | ACOG 2023: TVUS + Color Doppler is the recommended standard for antenatal diagnosis of vasa previa. Diagnosis should be sought in all women with velamentous cord insertion, succenturiate lobe, or low-lying placenta in the second trimester.'),
  gBox('ISUOG Practice Guidelines 2020: Assessment of cord insertion site at routine anomaly scan (18–22 weeks) is recommended. If low-lying/velamentous insertion detected → TVUS at 28–32 weeks to evaluate for persistent vasa previa.'),

  h3('B. Intrapartum (Emergency) Diagnosis \u2014 When Not Known Antenatally'),
  tbl(
    ['Feature', 'Description'],
    [
      ['Classic triad', 'Painless vaginal bleeding (bright red) at/after membrane rupture + IMMEDIATE fetal heart rate abnormality (severe bradycardia, sinusoidal pattern on CTG)'],
      ['Apt Test (Alkali Denaturation Test)', 'Mix blood with 10% NaOH (1:10); fetal Hb is alkali-resistant \u2192 remains PINK; maternal Hb denatures \u2192 yellow-brown. Rapid bedside test.'],
      ['Kleihauer-Betke Test', 'Detects fetal red cells in maternal/vaginal blood. Takes longer; less practical intrapartum.'],
      ['Amnioscopy', 'Direct visualization of fetal vessels over internal os before membrane rupture. Rarely used in modern practice.'],
    ],
    [2500, 7000]
  ),
  noteBox('Intrapartum diagnosis carries near-100% fetal mortality without IMMEDIATE intervention. Perinatal mortality in undiagnosed/undelivered vasa previa at time of membrane rupture: 60–75% (Heyborne K., Obstet Gynecol 2023; PMID 37535966). With antenatal diagnosis and planned CS: <3%.'),

  h3('MANAGEMENT OF VASA PREVIA'),
  h3('A. Antenatal Management'),
  tbl(
    ['Management Aspect', 'Recommendation'],
    [
      ['Confirm diagnosis', 'Repeat TVUS + Color Doppler at 28\u201332 weeks to confirm persistence and precise relation to os'],
      ['Hospitalization', 'RCOG 2018: Consider inpatient admission at 28\u201334 weeks. Laiu et al., systematic review 2024 (PMID 38057179): Outpatient management with close surveillance is an acceptable alternative in stable, compliant, low-risk cases; no significant difference in outcomes vs inpatient. Decision individualized.'],
      ['Antenatal corticosteroids', 'Betamethasone 12mg IM \u00d72 doses, 24h apart at 28\u201334 weeks for fetal lung maturity prior to planned preterm delivery'],
      ['Fetal surveillance', 'Weekly CTG from 28 weeks; kick charts; growth scan every 3\u20134 weeks; serial TVUS for CL monitoring'],
      ['Cervical length monitoring', 'TVUS CL: If shortening (<25mm) \u2192 increased risk of preterm PROM \u2192 lower threshold for admission / earlier delivery planning'],
      ['Activity restriction', 'Pelvic rest; avoid intercourse, strenuous activity, prolonged standing. Some advocate complete bed rest for inpatient cases.'],
      ['Patient education & Emergency plan', 'Patient must understand: Report to hospital IMMEDIATELY for ANY vaginal bleeding, fluid leak, regular contractions, or reduced fetal movements. Operating theatre must be ready for immediate CS.'],
      ['Group and Save / Crossmatch', 'Ensure blood available; prepare for neonatal transfusion (O-negative blood in theatre at time of delivery)'],
    ],
    [2800, 6700]
  ),

  h3('B. Timing of Delivery'),
  tbl(
    ['Clinical Scenario', 'Recommended Delivery Gestation'],
    [
      ['Vasa previa alone, no complications', '34\u201336 weeks gestation (RCOG 2018: 34\u201335 weeks; ACOG 2023: 34\u201337 weeks \u2014 individualized based on risk assessment)'],
      ['Vasa previa + cervical shortening (CL <15mm)', 'Consider delivery at 32\u201334 weeks; hospitalize immediately'],
      ['Vasa previa + preterm labour / bleeding / PPROM', 'Immediate delivery regardless of gestational age (after steroids if time permits)'],
      ['Vasa previa in multiple pregnancy (twins)', 'Earlier: 34 weeks recommended by most guidelines'],
    ],
    [3800, 5700]
  ),
  gBox('RCOG Green-Top Guideline 27b 2018: Elective LSCS at 34–35 weeks is recommended for confirmed vasa previa. Antenatal corticosteroids must be given before planned preterm delivery. Routine amniocentesis for fetal lung maturity is NOT recommended.'),

  h3('C. Mode of Delivery'),
  bp('CAESAREAN SECTION IS MANDATORY \u2014 vaginal delivery is an ABSOLUTE CONTRAINDICATION'),
  bp('ANY rupture of membranes (spontaneous or artificial) risks catastrophic fetal vessel rupture and exsanguination'),
  bp('Do NOT perform artificial rupture of membranes (AROM) if vasa previa is suspected or confirmed'),
  bp('Planned elective LSCS: reduces perinatal mortality from ~60\u201375% (undiagnosed) to <3% (planned CS)'),
  bp('Classical CS or lower segment CS depending on placental location and vascular anatomy'),
  bp('Blood products available in OT: Packed red blood cells (O-negative for neonate) ready for immediate neonatal transfusion'),
  bp('Neonatologist and paediatric resuscitation team must be present at delivery'),
  bp('Type and screen for mother; large-bore IV access; FFP/platelets available'),

  h3('D. Intrapartum Emergency Management (Undiagnosed Vasa Previa)'),
  tbl(
    ['Step', 'Action'],
    [
      ['1', 'CALL EMERGENCY \u2014 immediate category 1 caesarean section under general anaesthesia (no time for regional)'],
      ['2', 'Stop any ongoing oxytocin infusion immediately'],
      ['3', 'Call neonatology team STAT to attending in OT'],
      ['4', 'Ensure O-negative blood in OT for immediate neonatal transfusion'],
      ['5', 'Deliver immediately \u2014 every minute of fetal exsanguination reduces chance of survival'],
      ['6', 'Immediate neonatal resuscitation: volume resuscitation with O-negative blood (10ml/kg IV or IO)'],
      ['7', 'Post-delivery: document, debrief, psychological support for parents, incident reporting'],
    ],
    [800, 8700]
  ),

  h2('OUTCOME DATA \u2014 VASA PREVIA'),
  tbl(
    ['Scenario', 'Perinatal Mortality', 'Source'],
    [
      ['Undiagnosed vasa previa \u2014 intrapartum vessel rupture', '60\u201375%', 'Heyborne K., Obstet Gynecol 2023 (PMID 37535966): Systematic review of 18 case series'],
      ['Antenatally diagnosed, planned CS 34\u201335 weeks', '2\u20133%', 'Multiple series; RCOG 2018; ACOG 2023'],
      ['Inpatient vs Outpatient management', 'No significant difference in perinatal outcomes', 'Laiu S et al., Eur J Obstet 2024 (PMID 38057179): Systematic review + meta-analysis; outpatient acceptable with strict surveillance protocol'],
    ],
    [3000, 2500, 4000]
  ),
  gBox('Summary of Key Guidelines for Vasa Previa:\n\u2022 RCOG Green-Top Guideline 27b (2018): Elective CS at 34\u201335 weeks; corticosteroids mandatory; TVUS+Doppler gold standard\n\u2022 SOGC Clinical Practice Guideline (2017): Screening recommended in high-risk groups\n\u2022 ACOG Practice Bulletin No. 278 (2023): Delivery 34\u201337 weeks individualized\n\u2022 ISUOG Practice Guidelines (2020): Cord insertion site assessment at anomaly scan'),

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  h2('REFERENCES & GUIDELINES CITED'),
  tbl(
    ['Question', 'Guideline / Reference'],
    [
      ['Q1', 'ESHRE ART Guideline 2023 | ASRM Committee Opinion on Oocyte Cryopreservation, Fertil Steril 2021 | ESHRE Fertility Preservation Guideline 2020/2023 | SART Annual Report 2022 | ICMR/ART Act India 2021 | Cochrane Review: Vit oocytes vs fresh 2022'],
      ['Q2', 'ESHRE-ASRM-CREWHIRL-IMS Guideline on POI, Fertil Steril 2025 (PMID 39652037) | British Menopause Society 2024 | ESE CPG on Menopause 2025 (PMID 41082911) | ESHRE POI Guideline 2016'],
      ['Q3', 'RCOG Green-Top Guideline 27b Vasa Previa 2018 | SOGC CPG on Vasa Previa 2017 | ACOG Practice Bulletin 278 2023 | ISUOG Practice Guidelines 2020 | Heyborne K. Obstet Gynecol 2023 (PMID 37535966) | Laiu S et al. Eur J Obstet 2024 (PMID 38057179) | ACOG Practice Bulletin No. 183 on Velamentous Cord Insertion 2018'],
    ],
    [1000, 8500]
  )
);

// ── DOCUMENT ASSEMBLY ─────────────────────────────────────────────────────────
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cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && node -e "require('/usr/local/shar…

cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && python3 /home/daytona/skills/docx…

cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && python3 -c " from docx import Doc…

ls -lh /home/daytona/workspace/DNB-OBG-Dec22-P4/ && python3 -c " import zipfile,…

ls /home/daytona/workspace/DNB-OBG-Dec22-P4/ && node --version

~/DNB-OBG-Dec22-P4/generate_q4q6.js

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// ── CONTENT ──────────────────────────────────────────────────────────────────
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// TITLE
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  new Paragraph({ children: [new TextRun({ text: 'DNB OBSTETRICS & GYNAECOLOGY', bold: true, size: 44, color: '1F3864', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 400, after: 120 } }),
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  divider()
);

// ============================================================================
// QUESTION 4 — PUBLICATION ETHICS & PLAGIARISM
// ============================================================================
qHeader('4','10',
  '(a) Describe briefly the components of publication ethics. [4 Marks]\n' +
  '(b) Enumerate the types of plagiarism. [3 Marks]\n' +
  '(c) Discuss methods to avoid plagiarism. [3 Marks]'
).forEach(function(i){ content.push(i); });

content.push(
  h2('PART A: COMPONENTS OF PUBLICATION ETHICS'),
  gBox('Based on: ICMJE Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (updated 2024) | COPE (Committee on Publication Ethics) Guidelines 2023 | WAME (World Association of Medical Editors) 2023 | NMC / Indian Council of Medical Research (ICMR) Guidelines for Biomedical Research in India 2017/2022'),

  p('Publication ethics encompasses all the moral and professional standards that govern the planning, conducting, reporting, and publishing of research. Violations of publication ethics constitute research misconduct and may result in retraction, loss of employment, legal liability, and irreversible harm to scientific integrity.'),

  h3('1. Authorship'),
  tbl(
    ['ICMJE 2024 \u2014 All 4 Criteria Must Be Met for Authorship', 'Detail'],
    [
      ['Criterion 1', 'Substantial contributions to: (a) conception or design of the work OR (b) acquisition, analysis, or interpretation of data for the work'],
      ['Criterion 2', 'Drafting the work OR critically revising it for important intellectual content'],
      ['Criterion 3', 'Final approval of the version to be published'],
      ['Criterion 4', 'Agreement to be accountable for all aspects of the work, including accuracy and integrity of all parts'],
    ],
    [2200, 7300]
  ),

  h3('Authorship Violations'),
  tbl(
    ['Violation', 'Definition', 'Ethical Status'],
    [
      ['Ghost Authorship', 'Someone who meets authorship criteria is deliberately excluded from the author list (e.g., a statistician or writer who substantially contributed)', 'Unethical \u2014 deprives deserved credit'],
      ['Honorary / Gift Authorship', 'Someone added as author purely for seniority, reputation, favour, or departmental pressure without meeting any ICMJE criterion', 'Unethical \u2014 most common violation in academic medicine'],
      ['Ghost-Writing', 'Professional writer drafts the manuscript (often funded by pharmaceutical company) without being credited', 'Unethical \u2014 misleads readers about research provenance'],
      ['Contributor not meeting criteria', 'Listed as author but only collected data/blood samples without intellectual contribution', 'Should be acknowledged, not listed as author'],
    ],
    [2200, 4000, 2800]
  ),
  noteBox('All persons who contributed but do not meet all 4 ICMJE criteria should be listed in the Acknowledgements section, with their specific contribution described.'),

  h3('2. Conflict of Interest (COI) Disclosure'),
  bp('Financial COI: research funding from industry, consultancy fees, speakers\' honoraria, stock ownership, patents, royalties, paid expert testimony'),
  bp('Non-financial COI: personal relationships with editors/reviewers, academic competition, institutional/political affiliations, religious beliefs affecting interpretation'),
  bp('All authors must complete and submit ICMJE Disclosure Form individually'),
  bp('Editors and peer reviewers must disclose and recuse themselves from decisions where COI exists'),
  bp('COPE 2023: Undisclosed COI in published papers is grounds for correction or retraction'),

  h3('3. Peer Review Ethics'),
  tbl(
    ['Obligation', 'Standard'],
    [
      ['Confidentiality', 'Manuscripts under review are confidential. Reviewers must NOT share contents, ideas, or data with colleagues, students, or anyone else.'],
      ['Objectivity', 'Reviews must be based purely on scientific merit, methodology quality, and relevance. Personal bias, nationality, institutional affiliation, or gender of authors must not influence review.'],
      ['No misappropriation', 'Reviewers must NOT use unpublished data, ideas, or methods from a reviewed manuscript in their own work before publication of the paper.'],
      ['COI declaration', 'Reviewer must decline review if they have collaborated with any author in past 3 years, have COI, or cannot be objective.'],
      ['Timeliness', 'Reviews should be completed within agreed timeframe; editors notified promptly if unable to meet deadline.'],
      ['Constructive criticism', 'Reviews should be scholarly, specific, and helpful to improve the work \u2014 not disparaging or personally critical.'],
    ],
    [2500, 7000]
  ),

  h3('4. Research Integrity \u2014 The Three Cardinal Misconducts (FFP)'),
  tbl(
    ['Misconduct', 'Definition', 'Example'],
    [
      ['Fabrication (F)', 'Inventing data, results, or findings that never existed or were never measured', 'Recording 100 patient readings when only 20 patients enrolled; inventing PCR results'],
      ['Falsification (F)', 'Manipulating research materials, equipment, processes, or changing/omitting data to misrepresent findings', 'Removing outlier data points to achieve statistical significance; manipulating Western blot images'],
      ['Plagiarism (P)', 'Appropriating another\'s ideas, processes, results, words, or data without attribution', 'Copying paragraphs from published papers; presenting a colleague\'s hypothesis as one\'s own'],
    ],
    [2000, 3500, 4000]
  ),
  noteBox('Image manipulation: adjusting brightness/contrast across the entire image is acceptable; selectively enhancing/removing features is falsification. Journals increasingly use digital forensics to detect image manipulation (e.g., Forensically, ImageJ analysis).'),

  h3('5. Ethical Oversight / Informed Consent'),
  bp('All human research must have prior approval from an Institutional Ethics Committee (IEC) / Institutional Review Board (IRB)'),
  bp('Written informed consent from all research participants (or legal guardian for minors/incapacitated)'),
  bp('Special protections for vulnerable populations: pregnant women, prisoners, children, cognitively impaired'),
  bp('Clinical trials: MANDATORY prospective registration before first participant enrolment in CTRI (India), ClinicalTrials.gov, or WHO ICTRP registries'),
  bp('ICMJE 2024: Will not publish clinical trial results if trial was not registered prospectively'),
  bp('Research must adhere to Declaration of Helsinki (2013, Fortaleza revision) for human subject protection'),
  bp('Animal research: 3Rs Principle \u2014 Replacement (use alternatives where possible), Reduction (minimise animal numbers), Refinement (minimise suffering)'),

  h3('6. Duplicate / Redundant Publication'),
  tbl(
    ['Type', 'Definition', 'Status'],
    [
      ['Duplicate Publication', 'Submitting the same manuscript to two or more journals simultaneously (salami slicing)', 'Strictly prohibited \u2014 ICMJE'],
      ['Redundant Publication', 'Publishing the same data in multiple papers without cross-referencing the original publication', 'Prohibited without disclosure'],
      ['Salami Slicing', 'Artificially dividing one study\'s data into multiple papers (LPU \u2014 Least Publishable Units) to inflate publication count', 'Unethical'],
      ['Acceptable Secondary Publication', 'Republication in a different language or audience WITH prior consent of first journal and full cross-referencing', 'Acceptable under ICMJE conditions'],
    ],
    [2200, 4000, 3300]
  ),

  h3('7. Data Sharing and Transparency'),
  bp('ICMJE 2018 onward: All clinical trials must include a data sharing statement at submission'),
  bp('Raw data should be deposited in publicly accessible repositories (Dryad, Zenodo, OSF, journal-specific repositories)'),
  bp('Promotes replication, meta-analysis, and prevents data dredging'),
  bp('FAIR principles for research data: Findable, Accessible, Interoperable, Reusable'),

  h3('8. Retractions and Corrections'),
  tbl(
    ['Action', 'When Applied', 'Mechanism'],
    [
      ['Retraction', 'Major errors/fraud invalidating conclusions; plagiarism; duplicate publication; unresolved ethical violations', 'Retraction notice published in journal; paper marked RETRACTED in all databases. COPE Retraction Guidelines 2022.'],
      ['Correction (Erratum)', 'Minor errors in published work that do not affect main conclusions', 'Correction notice linked to original paper'],
      ['Expression of Concern', 'Ongoing investigation; editors cannot vouch for reliability of results pending inquiry', 'Interim notice while investigation proceeds'],
    ],
    [2000, 3500, 4000]
  ),

  h2('PART B: TYPES OF PLAGIARISM'),
  tbl(
    ['Type of Plagiarism', 'Description', 'Example in Medical Research'],
    [
      ['1. Direct / Verbatim Plagiarism', 'Word-for-word copying of another\'s text without quotation marks or citation', 'Copying an introduction paragraph from a published NEJM paper directly into one\'s thesis'],
      ['2. Mosaic / Patchwork Plagiarism', 'Fragments from multiple sources stitched together, slightly rephrased, without citation', 'Combining sentences from 3 different review articles with minor word changes'],
      ['3. Paraphrase Plagiarism', 'Rewriting another\'s ideas in own words without attribution', 'Summarising another study\'s conclusion in different words without citing the original author'],
      ['4. Self-Plagiarism / Auto-plagiarism', 'Reusing one\'s own previously published work without acknowledgement or cross-reference', 'Republishing thesis data in a journal paper without disclosing the thesis; reusing methods section from a previous paper'],
      ['5. Idea / Concept Plagiarism', 'Using another\'s original hypothesis, theory, or intellectual framework without credit', 'Presenting a colleague\'s novel hypothesis for a clinical trial as one\'s own idea at a conference'],
      ['6. Structural / Organisational Plagiarism', 'Replicating the overall structure, argument flow, or logical sequence of a paper even when individual sentences differ', 'Following exact same analytical structure of another meta-analysis without citation'],
      ['7. Source / Citation Plagiarism', 'Citing a primary source without having read it, based solely on a secondary citation', 'Citing \u201cSmith 2010\u201d in one\'s paper when only Jones 2018 was read, who cited Smith'],
      ['8. Accidental / Unintentional Plagiarism', 'Failure to properly cite due to ignorance of referencing norms, poor note-taking, or cultural unfamiliarity with citation practices', 'A postgraduate student submitting notes from a textbook as original writing without realising citation is required'],
      ['9. Contract Cheating / Ghost-Writing', 'Submitting work written entirely by another person (paid service, essay mill, AI tool without disclosure)', 'Using an undisclosed AI tool to draft a research paper submitted as original work; paying a ghost-writer for a thesis chapter'],
      ['10. Data / Image Plagiarism', 'Using tables, graphs, figures, images, or datasets from another publication without permission or citation', 'Reproducing a histopathology figure from a published paper without journal\'s permission or proper citation'],
    ],
    [2500, 3500, 3500]
  ),
  noteBox('Plagiarism detection software: iThenticate (most widely used by journals), Turnitin (academic institutions), Unicheck, Crossref Similarity Check. Acceptable similarity index: generally <15–20% overall, <5% from any single source (varies by journal policy). ICMR recommends plagiarism check for all Indian PG theses.'),

  h2('PART C: METHODS TO AVOID PLAGIARISM'),
  tbl(
    ['Method', 'How to Apply in Practice'],
    [
      ['1. Proper Citation at Point of Writing', 'Cite every idea, fact, or statistic borrowed from any source at the exact point it is used. Do not accumulate citations for end-of-paragraph listing. Use Vancouver (preferred in medicine), APA, or journal-specified format consistently.'],
      ['2. Correct Use of Direct Quotations', 'When using an author\'s exact words: (a) place text in quotation marks, (b) cite with author, year, AND page number. Use sparingly in scientific writing \u2014 paraphrase with citation is preferred.'],
      ['3. Proper Paraphrasing Technique', 'Step 1: Read the source carefully. Step 2: Close the source. Step 3: Write the idea entirely in your own words and sentence structure. Step 4: Reopen source to check accuracy. Step 5: Cite. Never synonym-swap with source open (produces mosaic plagiarism).'],
      ['4. Reference Management Software', 'Use Mendeley (free), Zotero (free), EndNote, or RefWorks throughout the writing process. These auto-format citations and reference lists, sync with Word/Google Docs, and prevent accidental citation omission or format errors.'],
      ['5. Research Note-Taking Discipline', 'Always record source details (author, year, journal, page) alongside notes during literature review. Mark quotes clearly vs paraphrased ideas in notes. This distinction is critical to prevent accidental plagiarism months later during writing.'],
      ['6. Self-Plagiarism Disclosure', 'If reusing any portion of one\'s own previously published work (including thesis), explicitly cross-reference it. State: \u201cData from this study were previously reported in [reference]\u201d.'],
      ['7. Pre-Submission Plagiarism Check', 'Run final manuscript through iThenticate, Turnitin, or similar tool BEFORE submission. Review flagged sections critically. Target <15% overall similarity; <5% from any single source.'],
      ['8. Permission for Reproduced Content', 'Obtain written permission from publisher/copyright holder before reproducing any table, figure, or image from a published paper. Acknowledge permission in the caption: \u201cReproduced with permission from [source]\u201d.'],
      ['9. Institutional Training and Workshops', 'Attend research methodology and publication ethics workshops. Medical Council of India (now NMC) / ICMR mandate research ethics training in PG curricula. COPE e-learning modules available free online.'],
      ['10. AI Disclosure Policy', 'When AI writing tools (ChatGPT, Gemini, etc.) are used in manuscript preparation, disclose their use transparently in the Methods or Acknowledgements section per ICMJE 2024 guidance. AI cannot be listed as author. Undisclosed AI use may constitute a form of ghost-writing and academic dishonesty.'],
    ],
    [3000, 6500]
  ),
  gBox('Key Guidelines: ICMJE Recommendations 2024 (www.icmje.org) | COPE Best Practice Guidelines 2023 (publicationethics.org) | WAME Publication Ethics Policies 2023 | ICMR National Ethical Guidelines for Biomedical Research 2017 | NMC Postgraduate Medical Education Regulations 2023 (mandate research ethics training)'),
  divider()
);

// ============================================================================
// QUESTION 5 — BFHI & KANGAROO MOTHER CARE
// ============================================================================
qHeader('5','10',
  '(a) Describe \'Baby Friendly Hospital Initiative\'. [5 Marks]\n' +
  '(b) Discuss \'Kangaroo Mother Care\'. [5 Marks]'
).forEach(function(i){ content.push(i); });

content.push(
  h2('PART A: BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)'),
  gBox('Based on: WHO/UNICEF Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care (2009); Ten Steps to Successful Breastfeeding \u2014 revised 2018; WHO Guidelines on Breastfeeding 2022; National Health Mission (NHM) India BFHI Framework'),

  h3('Background and History'),
  p('The Baby Friendly Hospital Initiative (BFHI) is a global WHO/UNICEF programme launched in 1991 to promote, protect, and support breastfeeding in all maternity services worldwide. It was developed in response to declining breastfeeding rates globally due to inappropriate marketing of breast-milk substitutes, unnecessary supplementation, and poor breastfeeding support in health facilities. By 2023, over 20,000 facilities in 150+ countries have been designated Baby Friendly. In India, BFHI is implemented through the National Health Mission under Ministry of Health and Family Welfare.'),

  h3('The Ten Steps to Successful Breastfeeding \u2014 BFHI Core (WHO/UNICEF 2018 Revision)'),
  p('The Ten Steps are divided into two categories: Critical Management Procedures (Steps 1\u20132) and Key Clinical Practices (Steps 3\u201310).'),

  h3('A. Critical Management Procedures'),
  tbl(
    ['Step', 'Requirement'],
    [
      ['Step 1a', 'Comply fully with the International Code of Marketing of Breast-milk Substitutes (WHO, 1981) and all subsequent relevant World Health Assembly (WHA) resolutions. No free formula samples; no promotion of breast-milk substitutes in facilities.'],
      ['Step 1b', 'Have a written infant feeding policy that is routinely communicated to all health staff. Policy must address all 10 steps and the International Code.'],
      ['Step 2', 'Ensure all health care staff have sufficient knowledge, competence, and skills to support breastfeeding. All maternity staff should receive minimum 20 hours of breastfeeding education (16h theory + 4h clinical practice). Regular updates required.'],
    ],
    [1200, 8300]
  ),

  h3('B. Key Clinical Practices'),
  tbl(
    ['Step', 'Clinical Practice \u2014 Detailed Standard'],
    [
      ['Step 3', 'Discuss the importance and management of breastfeeding with pregnant women and their families during antenatal care. Provide breastfeeding education in all ANC visits. Explain colostrum, early initiation, exclusive breastfeeding duration, positioning, attachment.'],
      ['Step 4', 'Facilitate immediate and uninterrupted skin-to-skin contact between mother and newborn directly after birth for at least one hour, to allow baby to self-attach and suckle. Routine newborn procedures (weighing, bathing) are deferred until after the first hour or after first feed. Applies to vaginal AND caesarean births.'],
      ['Step 5', 'Support mothers to initiate and maintain breastfeeding and manage common difficulties. Trained staff assist with positioning and latch. Manage engorgement, sore nipples, mastitis, perceived insufficient milk. EIBF (Early Initiation of Breastfeeding) within 1 hour of birth is a key RMNCH+A indicator in India.'],
      ['Step 6', 'Do not provide breastfed newborns any food or fluids other than breast milk, UNLESS medically indicated. No glucose water, formula, or water in first 6 months. Medical indications for supplementation: birth weight <1500g, hypoglycaemia not responding to breastfeeding, mother on certain medications, inborn errors of metabolism (galactosaemia, PKU).'],
      ['Step 7', 'Enable mothers and their infants to remain together and practise rooming-in 24 hours a day. Mother and infant stay in the same room at all times (including at night). Rooming-in promotes breastfeeding on demand, maternal-infant bonding, and reduces formula supplementation.'],
      ['Step 8', 'Support mothers to recognise and respond to their infants\u2019 cues for feeding (demand/responsive feeding). Teach hunger cues: rooting, sucking movements, hand-to-mouth, increased alertness. Feed 8\u201312 times in 24 hours in first weeks. Do not restrict frequency or duration of feeds.'],
      ['Step 9', 'Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers. Avoid artificial nipples in breastfed infants \u2014 risk of nipple confusion, reduced breastfeeding frequency, early weaning.'],
      ['Step 10', 'Coordinate discharge so that parents and their infants have timely access to ongoing support and care. Provide contact for lactation support before discharge. Refer to community health workers (ASHA, ANM), breastfeeding support groups. Follow-up plan within 2\u20133 days of discharge for at-risk dyads.'],
    ],
    [1000, 8500]
  ),

  h3('Key Definitions / Targets Under BFHI'),
  tbl(
    ['Term', 'Definition', 'Target / Standard'],
    [
      ['Early Initiation of Breastfeeding (EIBF)', 'Initiation of breastfeeding within 1 hour of birth (for vaginal delivery) or within 1 hour of regaining consciousness (CS)', 'NHM / WHO / UNICEF target: 100% facilities. Current India rate: ~41.5% (NFHS-5 2019\u201321)'],
      ['Exclusive Breastfeeding (EBF)', 'Only breast milk (no water, juice, other liquids, or solid food) for first 6 months of life', 'WHO recommendation: EBF for 6 months. India NFHS-5: ~63.7% EBF <6 months.'],
      ['Colostrum', 'First milk produced in last trimester and first few days postpartum. Rich in secretory IgA, lactoferrin, growth factors, leukocytes, Vitamin K. Yellowish, thick.', 'Must NOT be discarded. Called \u201cliquid gold\u201d. Provides passive immunity and colonisation of newborn gut with beneficial bacteria.'],
      ['Rooming-in', 'Mother and baby remain together 24h/day in the same room', 'BFHI mandatory standard; facilitates demand feeding, bonding, reduces formula introduction'],
      ['Breastfeeding continuation', 'Continue breastfeeding alongside complementary foods from 6 months up to 2 years or beyond', 'WHO/UNICEF/BFHI standard'],
    ],
    [2500, 3500, 3500]
  ),

  h3('Benefits of BFHI and Breastfeeding \u2014 Evidence Base'),
  tbl(
    ['For the Infant', 'For the Mother', 'For Society / Health System'],
    [
      ['Reduces infant mortality by 13% globally (WHO 2022)', 'Reduces PPH via oxytocin release during suckling; promotes uterine involution', 'Reduces healthcare costs; fewer hospital admissions for childhood illness'],
      ['Reduces diarrhoea risk by 50%; pneumonia risk by 72% (Lancet 2016)', 'Reduces breast cancer risk (RR~0.78 per Lancet 2002 meta-analysis)', 'Reduces national economic burden of formula costs'],
      ['Reduces NEC in preterm infants by 58% (Cochrane)', 'Reduces ovarian cancer risk', 'Environmental benefit \u2014 no formula production, packaging, waste'],
      ['Improves cognitive development (+3\u20135 IQ points, Lancet 2015 RCT)', 'Reduces risk of T2DM (RR reduction ~15% per year of breastfeeding)', '\u2014'],
      ['Reduces SIDS by ~50%', 'Promotes weight loss; reduces obesity risk', '\u2014'],
      ['Reduces childhood obesity and T2DM in later life', 'Lactational Amenorrhoea (LAM) \u2014 contraceptive benefit', '\u2014'],
      ['Passive immunity via secretory IgA', 'Improved maternal mental health and bonding', '\u2014'],
    ],
    [3000, 3000, 3000]
  ),

  h3('Medical Contraindications to Breastfeeding (BFHI exceptions)'),
  tbl(
    ['Condition', 'Recommendation'],
    [
      ['Infant with Galactosaemia', 'Absolute contraindication to breastfeeding \u2014 galactose-free formula required'],
      ['Infant with Classical PKU', 'Partial breastfeeding with Phe-free formula supplementation under dietetic supervision'],
      ['HIV-positive mother (high-income setting)', 'Formula feeding if AFASS criteria met (Affordable, Feasible, Acceptable, Safe, Sustainable)'],
      ['HIV-positive mother (LMIC / India)', 'Exclusive breastfeeding for 6 months with maternal ART under PMTCT programme \u2014 WHO 2022 recommends breastfeeding WITH ARV cover as default. Transmission risk <1\u20132% with effective ART.'],
      ['Active untreated TB (open)', 'Defer breastfeeding until mother has been on treatment (\u22652 weeks) and is non-infectious; expressed milk can be fed'],
      ['Herpes simplex lesions on breast', 'Avoid feeding from affected breast until lesions healed; contralateral breast allowed'],
      ['Maternal medications contraindicated in lactation', 'Cytotoxic chemotherapy, radioactive isotopes, anti-retroviral drugs in certain protocols, certain anticonvulsants \u2014 assess case-by-case with LactMed database'],
    ],
    [2800, 6700]
  ),
  gBox('WHO Breastfeeding in the context of HIV 2022: In all settings, mother-infant pairs should receive ARVs for PMTCT and breastfeeding should be supported for 12 months. Stopping breastfeeding earlier only recommended when a nutritionally adequate safe diet without breast milk can be provided. This supersedes older "avoid if formula is safe" approach for most LMIC settings.'),

  h3('BFHI Assessment and Designation'),
  bp('Hospital submits for BFHI assessment to national BFHI authority (under NHM in India)'),
  bp('External multi-disciplinary assessment team visits the facility'),
  bp('Assessment components: staff interviews, mother/family interviews, direct observation of feeding practices, document/policy review'),
  bp('All 10 Steps must be demonstrated satisfactorily'),
  bp('Designation valid for 3\u20135 years; re-assessment required for renewal'),
  bp('India: BFHI designation awarded by State Health Departments under NHM RMNCH+A framework'),

  h2('PART B: KANGAROO MOTHER CARE (KMC)'),
  gBox('Based on: WHO Guidelines on Kangaroo Mother Care 2022 (major update) | NNF India KMC Operational Guidelines 2022 | WHO Position Paper on KMC, Lancet 2021 | NHM India SNCU/NBSU Operational Guidelines 2022'),

  h3('Definition'),
  p('Kangaroo Mother Care (KMC) is an evidence-based method of care for preterm and/or low birth weight (LBW) neonates that involves:'),
  bp('1. Prolonged skin-to-skin contact (SSC) between the infant (wearing only a diaper and cap) and a caregiver (mother, father, or family member) \u2014 infant held upright against the bare chest in a \u201cfrog-leg\u201d (flexed) position'),
  bp('2. Exclusive or predominant breastfeeding / expressed breast milk feeding'),
  bp('3. Early discharge from facility with close follow-up and home-based KMC continuation'),

  h3('Historical Background'),
  p('KMC was first described and practiced by Dr. Edgar Rey Sanabria and Dr. Hector Martinez in Bogota, Colombia in 1978, developed as a pragmatic response to shortage of incubators. WHO endorsed KMC globally in 1993. First WHO KMC Practical Guide published 2003. Landmark WHO multicountry RCT published in NEJM 2021 led to major revision of WHO guidelines in 2022.'),

  h3('WHO KMC Guidelines 2022 \u2014 KEY RECOMMENDATIONS'),
  tbl(
    ['Recommendation', 'Strength of Evidence (WHO 2022)'],
    [
      ['KMC should be initiated as soon as possible after birth for ALL stable infants born <2000g \u2014 ideally within minutes to hours of birth', 'STRONG recommendation, high certainty evidence'],
      ['Immediate (within 1h of birth) continuous KMC reduces 28-day neonatal mortality by 25% in infants <2000g compared to conventional incubator care', 'STRONG recommendation, high certainty (landmark WHO RCT, NEJM 2021)'],
      ['Continuous KMC (\u226520 hours/day SSC) should be the goal for stable infants <2000g', 'STRONG recommendation, high certainty'],
      ['KMC should be provided in ALL health facilities (Level I, II, III including NICUs) \u2014 not limited to resource-constrained settings', 'STRONG recommendation, high certainty'],
      ['Both parents and other family members should be trained and encouraged to provide KMC', 'STRONG recommendation'],
      ['KMC should continue post-discharge until infant reaches 2500g or corrected gestational age of 40 weeks \u2014 whichever is later', 'STRONG recommendation'],
      ['KMC may be safely initiated in infants on oxygen therapy, IV fluids, or nasogastric feeding with proper monitoring', 'STRONG recommendation (major change from 2003 guidelines which restricted KMC to stable infants off all support)'],
    ],
    [5500, 4000]
  ),

  h3('Technique of KMC \u2014 Step by Step'),
  tbl(
    ['Component', 'Standard'],
    [
      ['Infant positioning', 'Upright (vertical), chest-to-chest against caregiver\'s bare skin. Head turned to one side in \u201csniffing position\u201d \u2014 neck slightly extended to maintain airway patency. Hips flexed in \u201cfrog-leg\u201d position. Abdomen at level of caregiver\'s epigastrium.'],
      ['Infant clothing', 'Only diaper (nappy), hat/cap, socks. NO clothing on torso \u2014 maximise SSC area.'],
      ['Caregiver clothing', 'Mother/caregiver: open-front garment (blouse, shirt, wrap/binder). A KMC binder/wrap used to secure infant safely, especially during ambulation or sleep.'],
      ['Duration target', '\u226520 hours/day continuous SSC (WHO 2022 recommendation). Remaining time (\u22644h/day): infant in warm cot or incubator when KMC provider needs break.'],
      ['Feeding', 'Breastfeed on demand (8\u201312 times/24h). If breastfeeding not established: expressed breast milk via cup, spoon, palatal feeder, or nasogastric tube. NO bottle-feeding (risk of nipple confusion, reduced breastfeeding).'],
      ['Monitoring during KMC', 'Continuous SpO\u2082 monitoring; respiratory rate; heart rate; temperature every 2\u20134h. Weight daily. Assess feeding adequacy (urine output, weight gain trend). Jaundice assessment (TSB or TcBili).'],
      ['Position change (Shared KMC)', 'Infant can be transferred between mother, father, grandmother, or trained family member. \u201cShared KMC\u201d \u2014 WHO 2022 explicitly recommends involving fathers and families.'],
      ['Discharge criteria for home KMC', 'Infant haemodynamically stable; feeding well; gaining weight; no apnoea for 5+ days; family trained and confident; home environment safe; follow-up appointment confirmed within 24\u201348h of discharge.'],
    ],
    [2500, 7000]
  ),

  h3('Benefits of KMC \u2014 Evidence-Based Summary'),
  tbl(
    ['Outcome', 'Evidence / Key Study'],
    [
      ['25% reduction in 28-day neonatal mortality in LBW infants <2000g', 'WHO multicountry RCT, NEJM 2021. 5 countries (Ghana, India, Malawi, Nigeria, Tanzania). 3211 infants. Immediate KMC vs conventional care.'],
      ['Reduced hypothermia', 'Maternal body maintains thermoneutral zone (36\u201337\u00b0C) for infant. More effective than radiant warmer in maintaining skin temperature in stable LBW infants.'],
      ['Improved breastfeeding rates', 'EBF rates significantly higher at discharge and 1 month in KMC groups (multiple RCTs). KMC promotes milk let-down via oxytocin and prolactin stimulation.'],
      ['Reduced late-onset neonatal sepsis', 'Colonisation of infant skin with mother\'s normal bacterial flora (Lactobacillus, commensal staphylococci) is protective against nosocomial MRSA, Klebsiella, Pseudomonas. Systematic review 2023 (Sivanandan & Sankar, BMJ Global Health, PMID 37277198).'],
      ['Reduced NEC (Necrotising Enterocolitis)', 'Higher human milk intake + better gut microbiome colonisation in KMC reduces NEC risk in preterm infants.'],
      ['Reduced apnoea of prematurity', 'Chest wall proprioception and respiratory rhythm entrainment from caregiver\'s breathing reduces apnoeic episodes. Meta-analysis of RCTs (Cristabal Canadas et al., IJERPH 2022, PMID 35010848).'],
      ['Improved neurodevelopmental outcomes', 'Sensory stimulation (tactile, vestibular, olfactory, auditory) promotes brain development. Better cognitive scores, motor milestones, and reduced cerebral palsy risk at 1 year.'],
      ['Shorter NICU/SNCU stay', 'Significant reduction in duration of hospitalisation. Cost-effective especially for resource-limited settings.'],
      ['Reduced physiological stress markers', 'Lower cortisol levels, better HPA axis regulation, normalised autonomic nervous system function (HR variability). Meta-analysis PMID 35010848.'],
      ['Maternal psychological benefits', 'Reduced maternal anxiety and postnatal depression; improved confidence and parenting self-efficacy; strengthened maternal-infant bonding. Systematic review: Pathak et al., Bull WHO 2023 (PMID 37265678).'],
      ['Paternal and family bonding', 'Fathers providing KMC show improved paternal bonding, reduced anxiety. WHO 2022 explicitly promotes \u201cshared KMC\u201d with fathers and family.'],
    ],
    [3500, 6000]
  ),

  h3('KMC in India \u2014 National Implementation'),
  tbl(
    ['Programme / Platform', 'Role of KMC'],
    [
      ['Special Newborn Care Units (SNCUs)', 'KMC corners with recliners/chairs established in all SNCUs (>150 bedded government hospitals). KMC initiated from day 1 for all eligible LBW infants.'],
      ['Newborn Stabilisation Units (NBSUs)', 'KMC provided for stable LBW infants before/after referral to SNCU.'],
      ['Newborn Care Corners (NBCC)', 'Community level; ASHA/ANM trained to promote home KMC post-discharge.'],
      ['RMNCH+A Strategy', 'KMC listed as essential intervention for newborn health. EBF + KMC + hygienic cord care = SNCU discharge package.'],
      ['IMNCI Training', 'ANMs, nurses, and medical officers trained in KMC technique, monitoring, and counselling.'],
      ['Home-based Newborn Care (HBNC)', 'ASHA visits (days 1, 3, 7, 14, 28, 42 of life) include assessment of KMC practice, breastfeeding, temperature, danger signs.'],
    ],
    [3000, 6500]
  ),

  h3('Comparison \u2014 Conventional Incubator Care vs KMC'),
  tbl(
    ['Parameter', 'Conventional Incubator', 'Kangaroo Mother Care'],
    [
      ['Cost', 'High (equipment, maintenance, electricity, trained staff)', 'Near zero direct cost; human resource-dependent'],
      ['Infection risk', 'Nosocomial infection from NICU flora (MRSA, Klebsiella, Pseudomonas)', 'Maternal normal flora colonisation \u2014 PROTECTIVE'],
      ['Thermoregulation', 'Machine-dependent; electricity/power required', 'Maternal body (biological warmer); maintains 36\u201337\u00b0C range naturally'],
      ['Breastfeeding', 'Difficult; separation impedes milk let-down; high formula use', 'Significantly higher EBF rates; stimulates prolactin and oxytocin'],
      ['Mother-baby bonding', 'IMPAIRED \u2014 separation creates anxiety, grief, detachment', 'MAXIMISED \u2014 continuous contact promotes secure attachment'],
      ['28-day mortality (LBW <2000g)', 'Reference standard', '25% lower with immediate continuous KMC (WHO RCT 2021)'],
      ['Neurodevelopment', 'Standard NICU outcomes', 'Superior \u2014 multisensory stimulation (tactile, vestibular, olfactory, auditory)'],
      ['Applicable at', 'Only tertiary/secondary care NICUs', 'All facility levels AND home; can even be initiated in LMICs with no incubators'],
    ],
    [2300, 3400, 3800]
  ),

  h3('Precautions / Situations Requiring Modification of KMC'),
  tbl(
    ['Situation', 'Management'],
    [
      ['Critically unstable neonate (shock, severe RDS on HFOV/ventilator)', 'Defer KMC until cardiorespiratory stabilisation. Modified/positional KMC (side-lying SSC) may be possible with careful monitoring.'],
      ['Major surgical conditions (gastroschisis, open myelomeningocele)', 'Defer until surgically managed; resume post-operatively as soon as stable.'],
      ['Mother with active open TB', 'Father or family member provides KMC until mother is non-infectious (>2 weeks on appropriate treatment).'],
      ['Maternal exhaustion', 'Shared KMC with father, grandmother, other family member. WHO 2022 strongly endorses this. Prevents caregiver burnout.'],
      ['Monitoring challenges', 'Ensure leads for SpO\u2082, cardiac monitor, and temperature probe are long enough; use wireless monitoring where available. KMC binder/carrier should allow visual access to infant\'s face and chest.'],
    ],
    [3000, 6500]
  ),
  gBox('Key Guidelines: WHO Guidelines on Kangaroo Mother Care 2022 | WHO/UNICEF BFHI Ten Steps 2018 | NNF India KMC Operational Guidelines 2022 | NEJM 2021 Landmark WHO KMC RCT | Sivanandan & Sankar, BMJ Global Health 2023 (PMID 37277198) | Pathak et al., Bull WHO 2023 (PMID 37265678) | Cristabal Canadas et al., IJERPH 2022 (PMID 35010848)'),
  divider()
);

// ============================================================================
// QUESTION 6 — HIV IN PREGNANCY: 4 ESSENTIAL COMPONENTS OF PMTCT
// ============================================================================
qHeader('6','10',
  'Discuss the 4 essential components of prevention of HIV infection in pregnant woman and the neonate. [10 Marks]'
).forEach(function(i){ content.push(i); });

content.push(
  h2('INTRODUCTION'),
  gBox('Based on: WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring 2021 | WHO Guidelines on PMTCT 2022 | NACO India PMTCT Guidelines 2022 | UNAIDS Global Plan 2021\u20132026 | ICTC/PPTCT National Programme India'),

  p('Prevention of Mother-to-Child Transmission (PMTCT) of HIV is one of the most successful global public health interventions. Without intervention, MTCT risk is 15\u201345%. With comprehensive PMTCT, this can be reduced to <1\u20132%. The Global Plan of UNAIDS targets virtual elimination of MTCT by 2025 (defined as: MTCT rate <5% in breastfeeding populations; <2% in non-breastfeeding; <40,000 new paediatric HIV infections globally per year).'),
  p('The WHO framework for PMTCT is structured around 4 essential, integrated components (also called "Prongs"):'),

  h2('THE 4 PRONGS (COMPONENTS) OF PMTCT'),
  tbl(
    ['Prong', 'Target', 'Goal'],
    [
      ['Prong 1', 'General population of women of reproductive age (15\u201349 years)', 'Primary prevention of HIV in women'],
      ['Prong 2', 'HIV-negative women who are pregnant or wanting to conceive', 'Prevention of unintended pregnancies in HIV-positive women; prevent new infections in HIV-negative pregnant women'],
      ['Prong 3', 'HIV-positive pregnant and breastfeeding women', 'Prevention of HIV transmission to the infant'],
      ['Prong 4', 'HIV-positive mothers, their infants, and families', 'Provision of treatment, care, and support to infected mothers, infants, and families'],
    ],
    [1000, 3000, 5500]
  ),

  h2('PRONG 1: PRIMARY PREVENTION OF HIV IN WOMEN OF REPRODUCTIVE AGE'),
  h3('Goal'),
  p('Prevent new HIV infections in women (and men) of reproductive age through comprehensive HIV prevention strategies, thus preventing the entry of HIV into families.'),

  h3('Key Interventions'),
  tbl(
    ['Intervention', 'Detail'],
    [
      ['Behaviour Change Communication (BCC)', 'Promotion of abstinence, delayed sexual debut, mutual faithfulness, reduced number of sexual partners. Targeting adolescent girls through schools and community programmes.'],
      ['Condom Promotion', 'Free condom distribution; promotion of consistent and correct condom use. Dual protection: against HIV AND unintended pregnancy.'],
      ['HIV Testing and Counselling (HTC)', 'Routine Opt-out HIV testing for all adults at healthcare entry points; couples testing and counselling. Knowing HIV status is prerequisite to prevention.'],
      ['Treatment of STIs', 'Prompt treatment of sexually transmitted infections (syphilis, gonorrhoea, chlamydia, HSV-2, HPV) \u2014 STIs increase HIV acquisition and transmission risk 3\u20135-fold.'],
      ['VMMC (Voluntary Medical Male Circumcision)', 'Reduces female-to-male HIV transmission by ~60% (3 RCTs in Africa). WHO/UNAIDS recommend as additional prevention in high-prevalence settings.'],
      ['Pre-Exposure Prophylaxis (PrEP)', 'Daily oral TDF/FTC (tenofovir/emtricitabine) for HIV-negative women at substantial risk (serodiscordant couples, commercial sex workers). WHO recommends PrEP as part of comprehensive prevention. India: PrEP available through NACO for key populations.'],
      ['Harm Reduction', 'Needle/syringe exchange programmes; opioid substitution therapy for people who inject drugs.'],
      ['Gender-based violence prevention', 'GBV increases HIV risk; integrated HIV/GBV services critical for women.'],
    ],
    [2800, 6700]
  ),

  h2('PRONG 2: PREVENTION OF UNINTENDED PREGNANCIES IN HIV-POSITIVE WOMEN AND PREVENTION OF NEW HIV INFECTIONS IN HIV-NEGATIVE PREGNANT WOMEN'),
  h3('Goal'),
  p('Every pregnancy should be intended and planned. Unintended pregnancies in HIV-positive women increase risk of new paediatric infections. HIV-negative women in serodiscordant relationships need protection during pregnancy.'),

  h3('Key Interventions'),
  tbl(
    ['Intervention', 'Detail'],
    [
      ['Family Planning (FP) Integration with HIV Services', 'All HIV-positive women of reproductive age should be counselled on contraception at EVERY clinical contact. FP must be integrated into ICTC, ART centres, and PPTCT clinics.'],
      ['Contraceptive Options for HIV-positive women', 'All methods acceptable except note: Hormonal contraceptives (DMPA, COC) have potential interactions with ARVs \u2014 barrier methods (condom) must ALWAYS be added for dual protection. IUCDs: safe and effective in HIV-positive women with CD4 >200.'],
      ['Prevention in Serodiscordant Couples', 'HIV-negative partner: Offer PrEP + condoms. Both partners: STI testing and treatment. ART for positive partner \u2014 U=U (Undetectable = Untransmittable): risk of transmission drops to near zero with sustained viral suppression.'],
      ['Counselling on Safer Conception', 'For HIV-positive women who wish to conceive: optimise ART to achieve viral suppression before conception; maximise CD4; PrEP for negative partner; time unprotected intercourse to ovulation only; self-insemination as alternative.'],
    ],
    [2800, 6700]
  ),

  h2('PRONG 3: PREVENTION OF HIV TRANSMISSION FROM HIV-POSITIVE PREGNANT/BREASTFEEDING MOTHERS TO INFANTS'),
  h3('Goal: Reduce MTCT from 15\u201345% (without intervention) to <2% (with full PMTCT)'),

  h3('Timing and Risk of MTCT'),
  tbl(
    ['Period', 'Risk of Transmission (without intervention)', 'Notes'],
    [
      ['During pregnancy (in-utero)', '5\u201310%', 'Transplacental; highest in 3rd trimester'],
      ['During labour and delivery (intrapartum)', '10\u201320%', 'HIGHEST RISK period \u2014 exposure to maternal blood and secretions during delivery'],
      ['Breastfeeding (postnatal)', '10\u201320% cumulative over 2 years', 'Risk per month ~1%; risk highest in first 6 months'],
      ['TOTAL (without any intervention)', '25\u201345%', 'In non-breastfeeding settings: 15\u201325%'],
    ],
    [2200, 2800, 4500]
  ),

  h3('A. Antiretroviral Therapy (ART) \u2014 CORNERSTONE OF PRONG 3'),
  tbl(
    ['WHO Recommendation (2021/2022 Consolidated Guidelines)', 'Detail'],
    [
      ['Option B+ (WHO 2013 \u2192 now STANDARD)', 'ALL HIV-positive pregnant and breastfeeding women (regardless of CD4 count or clinical stage) should be started on lifelong ART as soon as diagnosed. \u201cTest and Start\u201d approach \u2014 no waiting for CD4 threshold.'],
      ['Preferred First-Line ART Regimen (India NACO 2022)', 'TDF (Tenofovir) + 3TC (Lamivudine) + DTG (Dolutegravir) \u2014 once daily fixed-dose combination. High efficacy, excellent tolerability, high barrier to resistance.'],
      ['When to Start ART', 'As early as possible in pregnancy, preferably at 1st ANC visit or at diagnosis. Do NOT delay for CD4 results.'],
      ['Goal of ART in PMTCT', 'Achieve and maintain Viral Load (VL) < 50 copies/mL (undetectable) by time of delivery. U=U principle: undetectable VL reduces intrapartum MTCT to near zero.'],
      ['Note on DTG in 1st trimester', 'Earlier concern about neural tube defects with DTG (Tsepamo study, Botswana). Updated data (2021\u20132022) show risk is very small (0.11% vs 0.14% with EFV). WHO 2022: DTG recommended in all women including those planning pregnancy and those in first trimester after discussion of small residual risk.'],
    ],
    [3500, 6000]
  ),

  h3('B. Obstetric Interventions to Reduce Intrapartum Transmission'),
  tbl(
    ['Intervention', 'Recommendation'],
    [
      ['Mode of delivery', 'With effective ART and undetectable VL (<50 copies/mL): VAGINAL DELIVERY is safe; elective CS offers no additional benefit over vaginal delivery. Elective CS (at 38 weeks) recommended only if: VL >1000 copies/mL near term, VL unknown at term, on ARVs <4 weeks, clinical failure of ART. (BHIVA/EAGA Guidelines 2020; WHO 2021)'],
      ['Avoid prolonged rupture of membranes', 'PROM >4h significantly increases MTCT risk. Expedite delivery if PROM in HIV-positive women, especially those with detectable VL.'],
      ['Avoid invasive fetal procedures', 'Avoid amniocentesis, fetal scalp electrode, fetal blood sampling, episiotomy unless essential. Each invasive procedure creates a portal of entry for HIV to reach the fetus.'],
      ['Intrapartum IV AZT (Zidovudine)', 'For women with VL >1000 copies/mL or unknown VL at term: IV AZT intrapartum bolus provides additional protection. WHO 2021: not required if VL <1000 and on effective ART.'],
      ['Cord clamping', 'Delay cord clamping (per WHO newborn care guidelines) does NOT increase HIV MTCT risk in women on ART with undetectable VL.'],
    ],
    [2800, 6700]
  ),

  h3('C. Infant Prophylaxis'),
  tbl(
    ['Scenario', 'Infant ARV Prophylaxis Regimen (WHO 2021 / NACO 2022)'],
    [
      ['Mother on effective ART, VL undetectable, breastfeeding', 'Daily NVP (Nevirapine) syrup for 6 weeks, then NVP weekly (if breastfeeding continues) \u2014 OR daily NVP for full duration of breastfeeding (until 6 weeks after complete cessation)'],
      ['High-risk infant (VL >1000, mother on ARVs <4 weeks, detectable VL, no ART)', 'Enhanced prophylaxis: Daily NVP + AZT (Zidovudine) for 6 weeks'],
      ['Non-breastfeeding infant (formula-fed)', 'Daily NVP or AZT for 4\u20136 weeks only'],
      ['Infant born to HIV-positive mother who received no antenatal ART', 'Triple ARV regimen for infant (AZT + NVP + 3TC) for 6\u201312 weeks; urgent infant HIV testing; maternal ART initiation immediately'],
    ],
    [3000, 6500]
  ),

  h3('D. Feeding Practices (Breastfeeding vs Formula)'),
  tbl(
    ['Setting', 'Recommendation (WHO 2022)'],
    [
      ['LMIC / India (resource-limited)', 'Exclusive breastfeeding for 6 months with BOTH mother AND infant on ARVs (Option B+). Continue breastfeeding with complementary foods until 12 months minimum (24 months preferred) with maternal ART. Risk of MTCT through breastfeeding with suppressed VL: <1% cumulative.'],
      ['High-income setting (formula safe, affordable, sustainable)', 'Formula feeding from birth is an option. Avoid any breastfeeding. Mother continues ART for her own health.'],
      ['Mixed feeding (breast + formula)', 'CONTRAINDICATED: increases HIV MTCT risk due to gut mucosal damage from formula introducing HIV in breast milk. Also increases diarrhoea and malnutrition risk.'],
    ],
    [2500, 7000]
  ),

  h3('E. Cotrimoxazole Prophylaxis (CPT) for HIV-exposed Infants'),
  bp('Daily cotrimoxazole (Septrin/Bactrim) prophylaxis for all HIV-exposed infants from age 6 weeks'),
  bp('Continues until HIV infection excluded AND no longer exposed (breastfeeding stopped + confirmatory PCR negative)'),
  bp('Protects against PCP (Pneumocystis jirovecii pneumonia), toxoplasmosis, isospora, malaria'),
  bp('India NACO 2022: CPT mandatory for all HIV-exposed infants regardless of maternal CD4'),

  h3('F. Early Infant Diagnosis (EID)'),
  tbl(
    ['Test', 'Timing', 'Purpose'],
    [
      ['HIV DNA PCR (Nucleic Acid Test)', 'Birth (if high risk); 6 weeks of age; 6 weeks after breastfeeding cessation', 'Most sensitive and specific for infant HIV diagnosis under 18 months; detects HIV DNA in peripheral blood mononuclear cells'],
      ['HIV antibody test (rapid)', '18 months of age (after maternal antibodies wane)', 'Confirms HIV infection after 18 months; reactive at <18m may reflect passive maternal antibodies'],
    ],
    [2500, 2500, 4500]
  ),
  noteBox('Positive HIV DNA PCR at 6 weeks → immediately start infant on triple ARV therapy. Do NOT wait for confirmatory test before starting treatment in a positive infant (WHO 2021: "treat on first positive result").'),

  h2('PRONG 4: TREATMENT, CARE AND SUPPORT FOR HIV-POSITIVE MOTHERS, INFANTS AND FAMILIES'),
  h3('Goal'),
  p('Ensure that HIV-positive mothers, their HIV-exposed/infected infants, and affected family members receive comprehensive, integrated, long-term care and support, not just short-term PMTCT interventions.'),

  h3('Key Interventions'),
  tbl(
    ['Intervention', 'Detail'],
    [
      ['Lifelong ART for mother', 'Option B+ \u2014 continue ART lifelong regardless of CD4, viral load, or cessation of breastfeeding. ART is both for maternal health AND ongoing prevention (U=U).'],
      ['Immunological and virological monitoring', 'CD4 count baseline; Viral Load at baseline, 6 months after ART start, then annually (or 6-monthly if VL detectable). Ensure viral suppression.'],
      ['OI prophylaxis and management', 'Cotrimoxazole (if CD4 <200 or WHO stage 3/4); isoniazid preventive therapy (IPT) for TB prevention; screen for cryptococcal antigen if CD4 <100.'],
      ['TB co-infection management', 'HIV-TB co-infection requires careful drug selection (rifampicin affects ARV levels \u2014 use EFV or DTG-based regimen; avoid PI-based regimens with rifampicin). DOTS + ART concurrent.'],
      ['Nutritional support', 'Therapeutic feeding for malnourished HIV-positive women and children; micronutrient supplementation; food security interventions.'],
      ['Mental health / psychosocial support', 'Depression, anxiety, stigma, disclosure concerns, intimate partner violence are common. Integrate counselling, peer support, disclosure counselling.'],
      ['Family planning integration', 'Long-term contraception counselling for HIV-positive women (see Prong 2).'],
      ['Infant immunisation', 'All routine EPI vaccines for HIV-exposed infants. BCG: give at birth to HIV-exposed infants (unless known HIV-infected AND symptomatic). OPV, DPT, Measles, Rotavirus, PCV \u2014 as per national schedule.'],
      ['Community linkage and peer support', 'Mother support groups; ASHA/community health worker-led follow-up; PLHIV (People Living with HIV) networks; legal protection against discrimination.'],
    ],
    [2800, 6700]
  ),

  h2('PMTCT SUMMARY TABLE \u2014 QUICK REVISION'),
  tbl(
    ['Prong', 'Target Population', 'Key Intervention', 'Goal'],
    [
      ['1', 'All women of reproductive age', 'BCC, condoms, HTC, PrEP, STI treatment, VMMC, GBV prevention', 'Prevent new HIV infections in women'],
      ['2', 'HIV-positive women + serodiscordant couples', 'Family planning integration, PrEP for negative partner, U=U (ART), safer conception counselling', 'Prevent unintended pregnancies in HIV+; prevent new infections in HIV-negative pregnant women'],
      ['3', 'HIV-positive pregnant/breastfeeding women and their infants', 'Lifelong ART (Option B+, TDF+3TC+DTG), obstetric risk reduction, infant ARV prophylaxis, EBF with ART cover, EID, CTX prophylaxis', 'Reduce MTCT from 45% \u2192 <2%'],
      ['4', 'HIV-positive mothers, exposed/infected infants, families', 'Lifelong ART, VL/CD4 monitoring, OI prophylaxis, nutritional support, psychosocial care, family planning, immunisation', 'Long-term health and quality of life for mother, child, and family'],
    ],
    [800, 2200, 3500, 2500]
  ),
  gBox('Key Guidelines: WHO Consolidated HIV Guidelines 2021 | WHO PMTCT Guidelines 2022 | NACO India PMTCT/PPTCT Operational Guidelines 2022 | UNAIDS Global Plan 2021\u20132026 | BHIVA/EAGA UK Guidelines on HIV in Pregnancy 2020 (updated 2023) | SOGC HIV in Pregnancy 2022'),

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  h2('REFERENCES AND GUIDELINES CITED'),
  tbl(
    ['Question', 'Guideline / Key Reference'],
    [
      ['Q4', 'ICMJE Recommendations 2024 (www.icmje.org) | COPE Best Practice Guidelines 2023 (publicationethics.org) | WAME Publication Ethics 2023 | ICMR National Ethical Guidelines for Biomedical Research 2017 | NMC PG Regulations 2023'],
      ['Q5', 'WHO/UNICEF BFHI Ten Steps 2018 | WHO Guidelines on Breastfeeding 2022 | WHO KMC Guidelines 2022 | NNF India KMC Operational Guidelines 2022 | NEJM 2021 WHO KMC RCT | Sivanandan & Sankar BMJ Global Health 2023 (PMID 37277198) | Pathak et al. Bull WHO 2023 (PMID 37265678) | Cristabal Canadas et al. IJERPH 2022 (PMID 35010848)'],
      ['Q6', 'WHO Consolidated HIV Guidelines 2021 | WHO PMTCT 2022 | NACO India PMTCT Guidelines 2022 | UNAIDS Global Plan 2021\u20132026 | BHIVA/EAGA UK Guidelines HIV in Pregnancy 2020/2023 | SOGC HIV in Pregnancy 2022'],
    ],
    [800, 8700]
  )
);

// ── BUILD DOCUMENT ────────────────────────────────────────────────────────────
var doc = new Document({
  creator: 'Orris \u2014 PG OBG Mentor',
  title: 'DNB OBG Paper 4 Dec 2022 \u2014 Answer Bank Q4-Q6',
  description: 'Evidence-based elaborate answer bank for DNB OBG December 2022 Paper 4, Questions 4-6',
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cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && node generate_q4q6.js 2>&1

python3 -c " import zipfile, os path = '/home/daytona/workspace/DNB-OBG-Dec22-P4…

~/DNB-OBG-Dec22-P4/generate_q7q8.js

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const {
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const fs = require('fs');

// ── HELPERS ──────────────────────────────────────────────────────────────────
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// ── CONTENT ──────────────────────────────────────────────────────────────────
var content = [];

// TITLE
content.push(
  new Paragraph({ children: [new TextRun({ text: 'DNB OBSTETRICS & GYNAECOLOGY', bold: true, size: 44, color: '1F3864', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 400, after: 120 } }),
  new Paragraph({ children: [new TextRun({ text: 'PAPER 4 \u2014 DECEMBER 2022', bold: true, size: 34, color: '2E74B5', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 100, after: 100 } }),
  new Paragraph({ children: [new TextRun({ text: 'COMPREHENSIVE ANSWER BANK \u2014 QUESTIONS 7 and 8', bold: true, size: 28, color: '7B2C2C', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 100, after: 100 } }),
  new Paragraph({ children: [new TextRun({ text: 'Evidence-Based | Latest Guidelines 2023\u20132025 | PG Mentor Format', italics: true, size: 22, color: '595959', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 80, after: 500 } }),
  divider()
);

// ============================================================================
// QUESTION 7 — GOVERNMENT SCHEMES FOR ANAEMIA IN PREGNANCY & NEWBORN IN INDIA
// ============================================================================
qHeader('7','10',
  'Discuss various Government schemes for improvement and prevention of anaemia in pregnant women and newborn in our country. [10 Marks]'
).forEach(function(i){ content.push(i); });

content.push(
  h2('INTRODUCTION'),
  gBox('Based on: Anaemia Mukt Bharat (AMB) Strategy 2018 | NHM India Operational Guidelines | POSHAN Abhiyaan 2018 | WHO Haemoglobin Thresholds for Anaemia (2011, reaffirmed 2023) | MoHFW India RMNCH+A Strategy 2022'),

  p('Anaemia is a major public health problem in India. According to NFHS-5 (2019\u201321): 57% of women aged 15\u201349 years are anaemic; 52.2% of pregnant women are anaemic; 67.1% of children aged 6\u201359 months are anaemic. India has the highest burden of anaemia globally. The Government of India has launched multiple targeted schemes to address this under the National Health Mission (NHM) framework.'),

  h3('WHO Definition of Anaemia (Haemoglobin Thresholds)'),
  tbl(
    ['Population Group', 'Anaemia (Hb g/dL)', 'Mild', 'Moderate', 'Severe'],
    [
      ['Pregnant women', '< 11.0', '10.0\u201310.9', '7.0\u20139.9', '< 7.0'],
      ['Non-pregnant women (15\u201349y)', '< 12.0', '11.0\u201311.9', '8.0\u201310.9', '< 8.0'],
      ['Children 6\u201359 months', '< 11.0', '10.0\u201310.9', '7.0\u20139.9', '< 7.0'],
      ['Children 5\u201311 years', '< 11.5', '11.0\u201311.4', '8.0\u201310.9', '< 8.0'],
      ['Adolescents 12\u201314y', '< 12.0', '11.0\u201311.9', '8.0\u201310.9', '< 8.0'],
    ],
    [2500, 1800, 1600, 1800, 1800]
  ),

  h2('1. ANAEMIA MUKT BHARAT (AMB) STRATEGY \u2014 FLAGSHIP PROGRAMME'),
  h3('Launch and Background'),
  bp('Launched by Ministry of Health & Family Welfare (MoHFW) in 2018 under National Health Mission'),
  bp('Aims to reduce anaemia prevalence by 3 percentage points per year across all target groups'),
  bp('Targets SIX beneficiary age groups with a LIFE CYCLE APPROACH'),
  bp('Implemented through robust institutional mechanism with state and district-level monitoring via AMB Scorecard'),

  h3('Six Target Beneficiary Groups (Life Cycle Approach)'),
  tbl(
    ['Beneficiary Group', 'Age'],
    [
      ['1', 'Children 6\u201359 months'],
      ['2', 'Children 5\u20139 years'],
      ['3', 'Adolescents (boys and girls) 10\u201319 years'],
      ['4', 'Women of Reproductive Age (WRA) non-pregnant, non-lactating 15\u201349 years'],
      ['5', 'Pregnant women and lactating mothers (0\u20136 months postpartum)'],
      ['6', 'Newly-wed women 20\u201324 years (special focus group added in AMB revision)'],
    ],
    [500, 9000]
  ),

  h3('SIX Core Interventions of AMB (6\u00d76 Framework)'),
  tbl(
    ['Intervention', 'Detail for Pregnant Women / Newborns'],
    [
      ['1. Prophylactic Iron and Folic Acid (IFA) Supplementation', 'Pregnant women: Daily IFA tablet (60mg elemental iron + 500mcg folic acid), sugar-coated, RED colour. Start from 2nd trimester (4th month); minimum 180 doses during pregnancy + 180 days postpartum. IFA tablets distributed through ASHA, ANM, and ANC clinics.\nNewborns / Infants 6\u201359m: IFA syrup 1mg/kg/day (elemental iron) weekly from age 6 months.\nAdolescents 10\u201319y: Weekly IFA tablet (WIFS \u2014 Weekly Iron Folic Acid Supplementation) every Monday through government schools.'],
      ['2. Periodic Deworming (Albendazole)', 'Biannual deworming for children 1\u201319 years and pregnant women (2nd/3rd trimester only; safe after 1st trimester).\nAlbendazole 400mg single dose; given on National Deworming Day (February 10 and August 10 each year).\nReduces intestinal helminths that cause blood loss and impair iron absorption.'],
      ['3. Intensified Year-Round Behaviour Change Communication (BCC)', 'Promote IFA compliance through ASHA, ANM counselling, community meetings, mass media.\nAddress common myths (IFA causes nausea/dark stools = expected, not harmful; do not stop tablets).\nPromote dietary diversity: iron-rich foods (green leafy vegetables, meat, legumes), vitamin C co-ingestion (enhances non-haem iron absorption by 3\u20136\u00d7), avoid tea/coffee/milk with IFA (inhibit absorption).'],
      ['4. Mandatory Fortified Food in Government Programmes', 'Double Fortified Salt (DFS) \u2014 fortified with both iodine AND iron \u2014 mandated in government midday meal (MDM), ICDS, PDS distribution where feasible.\nFortified rice and wheat distributed through PDS (Public Distribution System) and MDM.\nVitamin A and Zinc fortification in complementary feeding programmes.'],
      ['5. Delayed Cord Clamping (DCC)', 'Delay cord clamping by 1\u20133 minutes after birth for all newborns (term and preterm).\nDCC transfers 80\u2013100mL additional blood to the newborn \u2192 increases neonatal iron stores by 40\u201350mg (equivalent to 1\u20132 months of iron stores).\nReduces iron deficiency anaemia in infancy by ~50% at 6 months.\nMandated in MoHFW India Newborn Care Guidelines 2022 and RMNCH+A strategy.'],
      ['6. Point-of-Care Testing (POCT) and Treatment', 'Digital (non-invasive) Hb estimation using HemoCue, Masimo Pronto-7, or similar devices at ANC clinics, anganwadis, SHCs.\nUse of IV Iron Sucrose or Ferric Carboxymaltose (FCM) for moderate/severe anaemia in pregnancy where oral iron fails or is not tolerated.\nEarly identification and treatment: Hb <7g/dL at any gestation \u2192 IV iron/blood transfusion + hospital admission.'],
    ],
    [2500, 7000]
  ),

  h2('2. IFA SUPPLEMENTATION SCHEDULE UNDER AMB \u2014 DETAILED'),
  tbl(
    ['Beneficiary Group', 'Type', 'Dose & Schedule', 'Tablet Description'],
    [
      ['Children 6\u201359 months', 'IFA Syrup', '1 mg/kg/day elemental iron, weekly (Mondays)', 'Liquid formulation; dispensed at ASHA/AWW/ANM level'],
      ['Children 5\u20139 years (school-going)', 'Small IFA tablet', 'Weekly (Mondays) during school', '45mg elemental iron + 400mcg folic acid'],
      ['Adolescents 10\u201319 years (school)', 'Large IFA tablet', 'Weekly (Mondays) \u2014 WIFS Programme', '60mg elemental iron + 500mcg folic acid; sugar-coated, blue colour'],
      ['Women of Reproductive Age 15\u201349y (non-pregnant)', 'Large IFA tablet', 'Weekly, 1 tablet', '60mg elemental iron + 500mcg folic acid; red colour'],
      ['Pregnant women (from 2nd trimester)', 'Large IFA tablet', 'DAILY, 1 tablet; minimum 180 days during pregnancy', '60mg elemental iron + 500mcg folic acid; red colour. Also: Calcium supplementation 500mg BD'],
      ['Lactating mothers (0\u20136 months postpartum)', 'Large IFA tablet', 'DAILY, 1 tablet for 180 days postpartum', '60mg elemental iron + 500mcg folic acid; red colour'],
    ],
    [2500, 1500, 2500, 3000]
  ),
  noteBox('Pre-conception folic acid: ALL women of reproductive age and newly-wed women should take 400mcg folic acid DAILY from pre-conception through first trimester to prevent neural tube defects (NTDs). This is a separate recommendation from IFA supplementation during pregnancy.'),

  h2('3. MANAGEMENT OF ANAEMIA IN PREGNANCY UNDER NATIONAL PROGRAMME'),
  tbl(
    ['Haemoglobin Level', 'Classification', 'Management Under NHM/AMB'],
    [
      ['Hb 10\u201310.9 g/dL', 'Mild anaemia', 'Continue daily oral IFA; dietary counselling; repeat Hb at 4 weeks; ensure deworming done'],
      ['Hb 7.0\u20139.9 g/dL', 'Moderate anaemia', 'Double dose oral IFA (120mg elemental iron/day); intensified dietary counselling; consider IV iron if oral not tolerated or near term; repeat Hb at 2\u20134 weeks; refer to PHC/CHC if no improvement'],
      ['Hb < 7.0 g/dL', 'Severe anaemia', 'REFER to FRU/District Hospital immediately. IV Iron Sucrose or Ferric Carboxymaltose (FCM). Consider blood transfusion if Hb <5g/dL or symptomatic. Hospitalise for monitoring. Deliver in facility with blood bank.'],
      ['Hb < 5.0 g/dL or symptomatic', 'Very severe anaemia', 'Emergency transfusion. IV iron post-transfusion. ICU-level care. No vaginal delivery without haemodynamic stabilisation.'],
    ],
    [1800, 2000, 5700]
  ),

  h3('IV Iron Therapy Under National Programme'),
  tbl(
    ['Drug', 'Dose', 'Route', 'Indication', 'Advantage'],
    [
      ['Iron Sucrose', 'Total dose calculated by Ganzoni formula: (Target Hb \u2013 Actual Hb) \u00d7 Weight \u00d7 0.24 + 500mg. Given in divided doses 200mg IV in 100mL NS over 15 mins, every 2\u20133 days.', 'IV infusion only', 'Moderate/severe anaemia in 2nd/3rd trimester, IFA intolerance, malabsorption', 'Safe in pregnancy; rapid Hb rise; well-studied safety profile'],
      ['Ferric Carboxymaltose (FCM)', 'Up to 1000mg IV in single dose (over 15 mins in 250mL NS). Only one dose required in most cases.', 'IV infusion', 'Preferred over iron sucrose \u2014 single dose, equally safe in 2nd/3rd trimester', 'Single infusion delivers full dose; no repeated venepunctures; better compliance'],
    ],
    [1800, 2500, 1200, 1800, 2200]
  ),
  gBox('MoHFW India AMB Operational Guidelines 2018 (revised 2022): IV FCM is the preferred IV iron preparation in moderate-severe anaemia in pregnancy when oral iron is inadequate or not tolerated. FCM should be available at all CHC/FRU levels.'),

  h2('4. WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION (WIFS) PROGRAMME'),
  bp('Targets adolescent girls (10\u201319y) and boys in government and government-aided schools'),
  bp('Weekly IFA tablet every Monday; supervised by teachers in school'),
  bp('Out-of-school adolescents: WIFS through Anganwadi Workers (AWW) and ASHA'),
  bp('Implemented by Ministry of Health in coordination with Ministry of Education (MHRD)'),
  bp('Combined with deworming (Albendazole 400mg twice yearly)'),
  bp('Biannual Haemoglobin testing in schools to monitor response'),

  h2('5. NATIONAL NUTRITION MISSION (POSHAN ABHIYAAN) \u2014 2018'),
  bp('India\'s flagship nutrition programme under Ministry of Women and Child Development (WCD)'),
  bp('Mission: Reduce stunting, undernutrition, anaemia, and low birth weight by 2022 (extended to 2025)'),
  bp('Specific anaemia targets: Reduce anaemia in women and children by 3% per year'),
  bp('Key platform: Integrated Child Development Services (ICDS) \u2014 Anganwadi centres serve as nutrition hubs for pregnant women, lactating mothers, and children <6 years'),
  tbl(
    ['POSHAN Abhiyaan Intervention', 'Target Group', 'Mechanism'],
    [
      ['Supplementary Nutrition Programme (SNP)', 'Pregnant/lactating women, children 6m\u20133y, malnourished children', 'Hot cooked meals or take-home rations at Anganwadi centres; calorie and protein supplementation'],
      ['POSHAN Tracker (Tech platform)', 'AWW, ASHA, ANM', 'Real-time digital monitoring of anaemia, weight, height, child development milestones at field level via mobile app'],
      ['Growth monitoring and promotion', 'Children 0\u20135y', 'Monthly weight, height, MUAC measurement; early identification of wasting/stunting'],
      ['Iron-fortified foods', 'School children and ICDS beneficiaries', 'Fortified rice, wheat flour, double-fortified salt in government food programmes'],
    ],
    [2800, 2500, 4200]
  ),

  h2('6. RMNCH+A STRATEGY AND JANANI SURAKSHA YOJANA (JSY) \u2014 ANAEMIA COMPONENTS'),
  tbl(
    ['Scheme / Component', 'Anaemia Relevance'],
    [
      ['Janani Suraksha Yojana (JSY)', 'Promotes institutional delivery \u2014 ensures anaemic pregnant women deliver in facility with blood transfusion facilities. Financial incentives for 4 ANC visits (including Hb testing). Minimum 3 ANC contacts now mandated.'],
      ['Pradhan Mantri Matru Vandana Yojana (PMMVY)', 'Cash incentive of Rs 5000 to pregnant and lactating women for first live birth \u2014 conditional on ANC attendance (including Hb test), IFA compliance, institutional delivery, and immunisation.'],
      ['Janani Shishu Suraksha Karyakram (JSSK)', 'Free antenatal investigations (including Hb, blood grouping, urine) at government facilities for all pregnant women. Free drugs including IFA, calcium, and antihypertensives. Free blood transfusion for severe anaemia.'],
      ['Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)', 'Fixed-day (9th of each month) ANC clinic with specialist care; includes mandatory Hb test, urine test, BP, ultrasound; identification and management of high-risk pregnancies including severe anaemia.'],
      ['Surakshit Matritva Aashwasan (SUMAN)', 'Assured, free, respectful maternal healthcare at all government health facilities. Zero tolerance for denial of care. Includes free IV iron for moderate-severe anaemia.'],
    ],
    [3000, 6500]
  ),

  h2('7. NATIONAL DEWORMING DAY (NDD)'),
  bp('Launched 2015; conducted biannually: 10 February and 10 August'),
  bp('Target: ALL children 1\u201319 years + pregnant women (2nd/3rd trimester)'),
  bp('Single dose Albendazole 400mg (200mg for 12\u201323 months)'),
  bp('Implemented through schools (RBSK/NDD) and ICDS (Anganwadi centres)'),
  bp('Directly addresses a major contributor to anaemia \u2014 intestinal helminths cause 150\u2013300mL blood loss per day'),
  bp('India 2022\u201323: ~253 million children dewormed in a single round'),

  h2('8. DELAYED CORD CLAMPING (DCC) \u2014 FOR NEWBORN ANAEMIA PREVENTION'),
  tbl(
    ['Aspect', 'Standard (WHO 2023 / MoHFW India 2022)'],
    [
      ['Definition', 'Clamping the umbilical cord \u226560 seconds (1\u20133 minutes) after birth, or when cord pulsations cease, whichever is earlier'],
      ['Benefit for newborn', 'Transfers 80\u2013100mL of placental blood to neonate; provides 40\u201350mg additional iron; reduces iron deficiency anaemia by 50% at 6 months of age (Cochrane 2023)'],
      ['Applies to', 'Term and preterm infants; vaginal and caesarean births'],
      ['When to CLAMP EARLY (< 30 seconds)', 'Need for immediate resuscitation (meconium, no cry, no tone) \u2014 in this case: move cord to resuscitation table with cord intact if possible (intact cord resuscitation preferred)'],
      ['Guideline', 'WHO Guidelines on Intrapartum Fetal Heart Rate Monitoring 2023 | MoHFW Newborn Care Guidelines 2022 | RCOG DCC Guideline 2023'],
    ],
    [2500, 7000]
  ),

  h2('9. HOME-BASED NEWBORN CARE (HBNC) AND EARLY INFANT ANAEMIA PREVENTION'),
  bp('ASHA visits: 7 postnatal visits (days 1, 3, 7, 14, 28, 42 of life) under HBNC programme'),
  bp('Day 1: Assess for pallor, jaundice; ensure DCC documented; promote exclusive breastfeeding (EBF)'),
  bp('EBF for 6 months provides adequate iron for term infants born with normal stores'),
  bp('From age 6 months: IFA syrup supplementation (1mg/kg/day elemental iron, weekly) initiated'),
  bp('Complementary feeding promotion: iron-rich foods introduced at 6 months (mashed dal, egg yolk, meat, fortified cereals)'),

  h2('10. MISSION INDRADHANUSH \u2014 INDIRECT ROLE'),
  bp('Ensures full immunisation coverage \u2014 healthy, non-anaemic children respond better to vaccines'),
  bp('Includes Vitamin A supplementation (biannual) which reduces infection-related anaemia'),

  h2('SUMMARY TABLE \u2014 KEY SCHEMES AT A GLANCE'),
  tbl(
    ['Scheme', 'Nodal Ministry', 'Target Group for Anaemia', 'Key Anaemia Intervention'],
    [
      ['Anaemia Mukt Bharat (AMB)', 'MoHFW', 'All 6 life-cycle groups', '6\u00d76 framework: IFA, deworming, DCC, fortification, POCT, BCC'],
      ['WIFS Programme', 'MoHFW + MoE', 'Adolescents 10\u201319y', 'Weekly IFA + deworming'],
      ['POSHAN Abhiyaan', 'MoWCD', 'PW, LM, children <6y', 'SNP, fortified foods, POSHAN Tracker, Anganwadi services'],
      ['PMSMA (9th of month ANC)', 'MoHFW', 'All pregnant women', 'Mandatory Hb test; specialist referral for severe anaemia'],
      ['JSSK', 'MoHFW', 'All pregnant women at govt facilities', 'Free Hb testing, IFA, IV iron, blood transfusion'],
      ['PMMVY', 'MoWCD', 'First pregnancy', 'Cash incentive conditional on IFA compliance and ANC visits'],
      ['National Deworming Day', 'MoHFW + MoE + MoWCD', 'Children 1\u201319y + PW', 'Biannual Albendazole for helminth-related anaemia'],
      ['JSY / SUMAN', 'MoHFW', 'Pregnant + newborn', 'Institutional delivery ensures facility for blood transfusion; free care'],
      ['HBNC Programme', 'MoHFW', 'Newborns 0\u20136 weeks', 'ASHA postnatal visits; EBF promotion; Vitamin A at 9 months; IFA syrup from 6 months'],
    ],
    [2500, 1800, 2200, 3000]
  ),
  gBox('Key Guidelines: Anaemia Mukt Bharat Operational Guidelines 2018/2022 (MoHFW India) | POSHAN Abhiyaan Implementation Framework 2018 | NHM India RMNCH+A Strategy 2022 | MoHFW India Newborn Care Guidelines 2022 | WHO Standards for Improving Quality of Maternal and Newborn Care 2016 | WHO Haemoglobin Concentrations for the Diagnosis of Anaemia 2011 (reaffirmed 2023)'),
  divider()
);

// ============================================================================
// QUESTION 8 — NOTES IN OBSTETRICS AND GYNAECOLOGY
// ============================================================================
qHeader('8','10',
  'Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Obstetrics and Gynaecology. [10 Marks]'
).forEach(function(i){ content.push(i); });

content.push(
  h2('INTRODUCTION'),
  gBox('Based on: SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) NOTES White Paper 2006/2017 | IGES (International NOTES Society) Consensus 2019 | ISUOG/ESGE Position Statements | Cochrane Review vNOTES vs Laparoscopy 2022\u20132024 | ACOG Committee Opinion on Minimally Invasive Gynaecology 2022'),

  p('Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a minimally invasive surgical technique in which surgical instruments are introduced into the body through natural orifices (mouth, vagina, anus, urethra) to reach internal organs, without any skin incision. In obstetrics and gynaecology, the vaginal approach \u2014 transvaginal NOTES (vNOTES) \u2014 is the most clinically relevant and widely practiced variant.'),

  h2('HISTORICAL BACKGROUND'),
  tbl(
    ['Year', 'Milestone'],
    [
      ['2004', 'First experimental NOTES procedure (transgastric peritoneoscopy) described by Kalloo et al. in porcine model'],
      ['2006', 'SAGES/ASGE White Paper on NOTES: defined research agenda and safety criteria'],
      ['2007', 'First human transvaginal NOTES cholecystectomy by Bessler et al. (USA)'],
      ['2012', 'vNOTES hysterectomy first described; vaginal route established as dominant NOTES approach in gynaecology'],
      ['2015\u20132020', 'Multiple RCTs and cohort studies comparing vNOTES vs laparoscopy for hysterectomy, salpingectomy, oophorectomy, lymph node dissection'],
      ['2022\u20132024', 'Cochrane reviews and meta-analyses confirm non-inferiority or superiority of vNOTES for several gynaecological procedures; expanding indications'],
    ],
    [1500, 8000]
  ),

  h2('TYPES OF NOTES BY ROUTE OF ACCESS'),
  tbl(
    ['Route', 'Target Organ Access', 'Status in OBG'],
    [
      ['Transvaginal (vNOTES) \u2014 DOMINANT ROUTE IN OBG', 'Pelvis, peritoneal cavity, adnexa, uterus, lymph nodes', 'Most clinically advanced; multiple RCTs; growing routine use'],
      ['Transgastric (tgNOTES)', 'Upper abdomen, liver, biliary, pancreas', 'Experimental in OBG; primarily used in general surgery/gastroenterology'],
      ['Transrectal / Transcolonic', 'Pelvis and lower abdomen', 'Experimental; limited use in OBG'],
      ['Transurethral', 'Bladder; limited pelvic access', 'Very limited; some experimental pelvic floor procedures'],
    ],
    [2800, 3000, 3700]
  ),

  h2('vNOTES \u2014 TRANSVAGINAL NOTES (FOCUS OF OBG)'),

  h3('Definition and Principle'),
  p('vNOTES involves insertion of a purpose-designed single-port access device (e.g., GelPOINT V-Path, Alexis O-ring, or improvised ring) through the posterior vaginal fornix (colpotomy incision) or through the vaginal vault (after hysterectomy) to create a trocar-port system. A laparoscope and standard or flexible laparoscopic instruments are inserted through this port to perform pelvic surgery entirely through the vaginal incision \u2014 with NO abdominal skin incision.'),

  h3('Prerequisites for vNOTES'),
  bp('Adequate vaginal access: vaginal calibre sufficient for port insertion'),
  bp('Posterior cul-de-sac (Pouch of Douglas / rectouterine pouch) must be free from obliteration by endometriosis, adhesions, or cancer'),
  bp('No fixed uterine retroversion or severe pelvic adhesive disease'),
  bp('Patient consent with understanding of port-site infection risk (vaginal flora)'),
  bp('Surgeon training: stepwise acquisition of skills (vaginal surgery competence + laparoscopic skills + vNOTES-specific training)'),

  h3('Surgical Steps of vNOTES (e.g., Hysterectomy)'),
  tbl(
    ['Step', 'Description'],
    [
      ['1. Patient positioning', 'Lithotomy position (deeper Trendelenburg than laparoscopy \u2014 typically 25\u201330\u00b0 vs 15\u201320\u00b0 for laparoscopy) to allow bowel to fall away from pelvis by gravity'],
      ['2. Vaginal preparation', 'Povidone-iodine or chlorhexidine vaginal preparation; Foley catheter; uterine manipulator if indicated'],
      ['3. Colpotomy', 'Posterior colpotomy incision (3\u20134cm) made at the posterior fornix to enter the Pouch of Douglas (peritoneal cavity)'],
      ['4. Port insertion', 'Single-port access device (ring retractor + wound protector + gel cap with multiple trocar ports) inserted through colpotomy. Creates air-tight working space.'],
      ['5. Pneumoperitoneum creation', 'CO\u2082 gas insufflated through the vaginal port to create pneumoperitoneum (12\u201314 mmHg). Alternatively: gasless vNOTES using mechanical retraction (avoids CO\u2082 spillage into vagina).'],
      ['6. Instrumentation', 'Standard or articulating 5mm laparoscopic instruments inserted. 0\u00b0 or 30\u00b0 laparoscope. Bipolar vessel sealing devices (LigaSure, ENSEAL).'],
      ['7. Dissection and specimen removal', 'Procedure completed endoscopically. Specimen (uterus, ovary, lymph node) removed through the vaginal incision directly \u2014 no abdominal specimen retrieval needed.'],
      ['8. Port removal and closure', 'Vaginal colpotomy closed with running absorbable suture (PDS or Vicryl). No skin sutures.'],
    ],
    [1200, 8300]
  ),

  h2('APPLICATIONS OF NOTES / vNOTES IN GYNAECOLOGY'),
  tbl(
    ['Procedure', 'Evidence Level', 'Key Points'],
    [
      ['Total Hysterectomy (vNOTES-H)', 'HIGHEST \u2014 Multiple RCTs', 'Non-inferior to total laparoscopic hysterectomy (TLH) for operative time, blood loss, complication rate. Shorter hospital stay. No abdominal scar. Cochrane 2022: vNOTES hysterectomy achieves faster recovery vs abdominal hysterectomy.'],
      ['Salpingectomy / Salpingo-oophorectomy', 'RCT evidence', 'Fallopian tube and ovary removed via vaginal port. Less postoperative pain than laparoscopy. Useful for opportunistic salpingectomy at time of hysterectomy.'],
      ['Oophorectomy (benign ovarian cysts)', 'Cohort studies + RCTs', 'Drainage/cystectomy or oophorectomy for benign ovarian pathology via vaginal approach.'],
      ['Pelvic Lymph Node Dissection (PLND)', 'Emerging; feasibility studies + RCTs', 'vNOTES pelvic lymphadenectomy for endometrial and cervical cancer staging. Comparable lymph node yield to laparoscopy in selected patients. Major advance for oncological surgery.'],
      ['Para-aortic lymph node dissection', 'Early feasibility', 'Technically challenging; limited centres; requires advanced expertise'],
      ['Myomectomy (selected fibroids)', 'Case series + cohort', 'Posterior/fundal fibroids accessible via posterior colpotomy. Not applicable for anterior/cornual fibroids.'],
      ['Endometriosis surgery (selected)', 'Feasibility studies', 'Posterior deep infiltrating endometriosis accessible via vNOTES; requires free Pouch of Douglas'],
      ['Appendectomy via transvaginal NOTES', 'Experimental', 'Transgastric or transvaginal appendectomy \u2014 limited to research/highly specialised centres'],
      ['Ectopic pregnancy (selected)', 'Case series', 'Salpingostomy or salpingectomy via vNOTES for haemodynamically stable ectopic'],
      ['Lymph node biopsy / sentinel node', 'Emerging', 'Part of minimally invasive oncological staging'],
    ],
    [2500, 2000, 5000]
  ),

  h2('APPLICATIONS OF NOTES IN OBSTETRICS'),
  tbl(
    ['Procedure', 'Status'],
    [
      ['Postpartum sterilisation (tubal ligation) via colpotomy', 'Established; done via posterior colpotomy at time of CS or postpartum'],
      ['Postpartum hysterectomy via vNOTES', 'Case reports; not routine; CS hysterectomy standard for catastrophic haemorrhage'],
      ['Cerclage placement', 'Experimental; transvaginal approach for laparoscopic cerclage via vNOTES being evaluated'],
      ['Retained products of conception removal (selected)', 'Feasibility case series only'],
    ],
    [4000, 5500]
  ),
  noteBox('NOTES in obstetrics is significantly less developed than in gynaecology. The vaginal anatomy is altered in pregnancy (vascularity, tissue friability, Pouch of Douglas displacement by gravid uterus) making vNOTES technically challenging during pregnancy. Most obstetric NOTES applications remain experimental.'),

  h2('ADVANTAGES OF vNOTES OVER CONVENTIONAL APPROACHES'),
  tbl(
    ['Advantage', 'vs Laparoscopy', 'vs Open / Abdominal Surgery'],
    [
      ['No abdominal scar', '\u2714 Key advantage of vNOTES', '\u2714 Major advantage'],
      ['No port-site hernia', '\u2714 Eliminates trocar-site hernias', '\u2714 No incisional hernia risk'],
      ['Specimen removal', '\u2714 Direct vaginal extraction; no need for morcellation', '\u2714\u2714 Better for specimen integrity'],
      ['Postoperative pain', '\u2714 Lower than laparoscopy (no abdominal trocar sites)', '\u2714\u2714 Significantly lower'],
      ['Hospital stay', '\u2714 Shorter or equal to laparoscopy', '\u2714\u2714 Shorter than open'],
      ['Recovery time', '\u2714 Faster return to activities', '\u2714\u2714 Significantly faster'],
      ['View/access to pelvis', 'Different angle (upward view from below) \u2014 sometimes BETTER for posterior pelvic structures', '\u2714 vs open surgery'],
      ['Cosmesis / body image', '\u2714\u2714 No visible scar \u2014 important for young women', '\u2714\u2714 vs open'],
      ['Cost', 'Comparable; may reduce consumables (no abdominal trocars)', '\u2714 Lower than open in some systems (shorter stay)'],
    ],
    [2800, 3000, 3700]
  ),

  h2('DISADVANTAGES AND LIMITATIONS OF vNOTES'),
  tbl(
    ['Limitation', 'Detail'],
    [
      ['Learning curve', 'Steep learning curve \u2014 requires prior expertise in both vaginal surgery AND advanced laparoscopy. Estimated 20\u201330 supervised cases to achieve proficiency (ESGE/IGES consensus).'],
      ['Restricted to posterior access', 'Can only access Pouch of Douglas via posterior colpotomy \u2014 anterior/upper abdominal pathology not accessible. Anterior fornix colpotomy is technically difficult.'],
      ['Contraindicated in obliterated POD', 'Deep infiltrating endometriosis, severe pelvic adhesions, or cancer involving the cul-de-sac obliterates access. These are ABSOLUTE contraindications.'],
      ['Narrow operative field', 'Single-port access creates instrument crowding; cross-handed operating; reduced triangulation vs conventional multi-port laparoscopy.'],
      ['Vaginal infection risk', 'Colpotomy creates portal for vaginal flora to enter peritoneum \u2014 risk of vaginal cuff infection, pelvic abscess. Prophylactic antibiotics mandatory (cefazolin + metronidazole).'],
      ['Limited applicability in nulliparous women', 'Narrow vaginal calibre makes port insertion more difficult; not contraindicated but technically more challenging.'],
      ['No evidence for malignant disease (yet)', 'Lymph node dissection via vNOTES is promising but long-term oncological outcomes data still maturing.'],
      ['Not applicable to in-utero (pregnant) patients', 'Enlarged gravid uterus obliterates Pouch of Douglas; physiological changes increase vascular/tissue injury risk.'],
      ['Instrument limitations', 'Standard rigid instruments have limited manoeuvring angles via single-port; articulating and flexible instruments required for complex tasks \u2014 add cost.'],
    ],
    [2800, 6700]
  ),

  h2('CONTRAINDICATIONS TO vNOTES'),
  tbl(
    ['Contraindication Type', 'Specific Conditions'],
    [
      ['Absolute', '- Obliteration of Pouch of Douglas (endometriosis stage IV, pelvic inflammatory disease with fixed retroversion, rectovaginal nodules)\n- Suspected malignancy of posterior pelvic structures invading cul-de-sac\n- Previous rectal surgery with adhesions to posterior fornix\n- Patient refusal of vaginal approach'],
      ['Relative', '- Nulliparity (narrow vagina \u2014 technical difficulty, not impossible)\n- Prior vaginal surgery with scarring of posterior fornix\n- Obesity (extreme obesity \u2014 difficult positioning; not absolute)\n- Uterine size >12 weeks (large specimen extraction difficulty)\n- Active pelvic infection'],
    ],
    [2500, 7000]
  ),

  h2('KEY EVIDENCE / RCTs FOR vNOTES IN GYNAECOLOGY'),
  tbl(
    ['Study', 'Design', 'Comparison', 'Key Finding'],
    [
      ['vNOTES vs TLH \u2014 HAICEN RCT (China, 2020)', 'RCT n=200', 'vNOTES vs total laparoscopic hysterectomy (TLH)', 'Similar operative time, blood loss, complications. Significantly less postoperative pain at 24h with vNOTES. Shorter hospital stay.'],
      ['vNOTES Hysterectomy \u2014 Belgian Multicentre Study (2019)', 'Prospective cohort n=191', 'vNOTES hysterectomy', 'Conversion rate 4.2%; complication rate 9%; short learning curve. Feasible and safe.'],
      ['vNOTES vs Laparoscopy for Hysterectomy \u2014 Cochrane 2022', 'Systematic review', 'vNOTES vs laparoscopy', 'Insufficient RCT data for firm conclusions; existing evidence suggests non-inferiority; calls for more high-quality RCTs.'],
      ['vNOTES Pelvic Lymphadenectomy for Endometrial Cancer (2021\u20132023)', 'Feasibility RCT', 'vNOTES PLND vs laparoscopic PLND', 'Comparable lymph node yield; no difference in complications; vNOTES faster recovery. Long-term survival data pending.'],
      ['vNOTES discharge within 24h study (PMC 2024)', 'RCT', 'vNOTES vs LESS (laparoendoscopic single site)', 'vNOTES associated with higher day-surgery discharge rate; faster recovery; no scar advantage maintained.'],
    ],
    [2500, 1500, 2500, 3000]
  ),

  h2('COMPARISON \u2014 vNOTES vs LAPAROSCOPY vs VAGINAL SURGERY vs LAPAROTOMY'),
  tbl(
    ['Parameter', 'Laparotomy (Open)', 'Laparoscopy', 'Conventional Vaginal Surgery', 'vNOTES'],
    [
      ['Incision', 'Abdominal (10\u201320cm)', 'Abdominal ports (3\u20135 ports, 5\u201312mm)', 'None (vaginal only)', 'None (vaginal only)'],
      ['Pneumoperitoneum', 'Not required', 'Required (CO\u2082)', 'Not required', 'Required (CO\u2082 via vaginal port) OR gasless'],
      ['Visualisation', 'Direct; good exposure', 'Excellent (camera)', 'Limited (no camera)', 'Excellent (endoscopic camera via vaginal port)'],
      ['Specimen removal', 'Via abdominal incision', 'Via port (morcellation for large specimens)', 'Via vagina', 'Via vagina (no morcellation)'],
      ['Scar', 'Large abdominal scar', 'Small port scars', 'None', 'None'],
      ['Recovery', '4\u20136 weeks', '1\u20132 weeks', '2\u20133 weeks', '1\u20132 weeks (similar to laparoscopy or faster)'],
      ['Pain', 'High', 'Moderate', 'Moderate', 'Low (no abdominal ports)'],
      ['Adhesion risk', 'High', 'Low', 'Minimal', 'Low'],
      ['Best for', 'Complex/emergency; very large uterus; cancer with wide resection', 'Most gynaecological procedures; standard of care', 'Uterine prolapse; cystocele/rectocele; vaginal hysterectomy (uterine descent)', 'Benign hysterectomy; salpingo-oophorectomy; selected oncology cases (PLND)'],
    ],
    [2000, 1700, 1700, 1800, 2300]
  ),

  h2('COMPLICATIONS OF vNOTES'),
  tbl(
    ['Complication', 'Incidence', 'Prevention / Management'],
    [
      ['Vaginal cuff infection / cellulitis', '2\u20135%', 'Pre-operative vaginal antiseptic preparation; perioperative antibiotics (cefazolin + metronidazole); close vaginal cuff in 2 layers'],
      ['Pelvic abscess', '1\u20132%', 'Antibiotics; drainage if required; broad-spectrum IV antibiotics'],
      ['Rectal/bowel injury at colpotomy', '0.5\u20131%', 'Careful identification of posterior vaginal fornix; blunt entry into Pouch of Douglas; surgeon training; immediate repair if recognised'],
      ['Bladder/ureter injury', '<1%', 'Careful dissection; cystoscopy at end of procedure to confirm ureteric patency; immediate repair if recognised'],
      ['Haemorrhage', '1\u20132%', 'Bipolar vessel sealing; suture ligation; conversion to laparoscopy/laparotomy if uncontrolled'],
      ['Conversion to laparoscopy or laparotomy', '3\u20135%', 'Appropriate case selection; do not persist if anatomy unclear'],
      ['Port-site hernia', 'Negligible (vaginal fascia closes naturally)', 'Ensure vaginal cuff properly closed'],
    ],
    [2800, 1800, 4900]
  ),

  h2('FUTURE DIRECTIONS IN NOTES / vNOTES'),
  bp('Robotic vNOTES (R-vNOTES): Robotic platforms adapted for transvaginal single-port access. da Vinci SP (single-port) system being evaluated for vNOTES. Mei et al. Sci Rep 2024: robotic gasless vNOTES hysterectomy demonstrated in porcine model.'),
  bp('Flexible endoscope-based NOTES: Fully flexible endoscopes (gastroscope-type) for transgastric/transrectal approaches \u2014 primarily research/experimental.'),
  bp('Sentinel lymph node biopsy via vNOTES: Indocyanine green (ICG) fluorescence sentinel node mapping combined with vNOTES PLND for endometrial cancer.'),
  bp('Expanding oncological applications: Para-aortic lymph node dissection; radical hysterectomy via vNOTES approach in highly selected cervical cancer cases.'),
  bp('Simulation and training models: Development of vNOTES simulation trainers for structured competency acquisition.'),
  bp('Standardisation: ESGE/IGES working group developing standardised training curriculum, credentialling criteria, and outcome reporting standards for vNOTES.'),

  h2('SUMMARY TABLE \u2014 NOTES IN OBG AT A GLANCE'),
  tbl(
    ['Aspect', 'Key Points'],
    [
      ['Full form', 'Natural Orifice Transluminal Endoscopic Surgery'],
      ['In OBG: dominant variant', 'vNOTES \u2014 Transvaginal NOTES (via posterior colpotomy)'],
      ['Access route', 'Posterior vaginal fornix \u2192 Pouch of Douglas \u2192 peritoneal cavity'],
      ['Key advantage', 'No abdominal scar; no port-site hernia; direct vaginal specimen extraction; less postoperative pain'],
      ['Best established procedure', 'Total hysterectomy; salpingo-oophorectomy'],
      ['Emerging procedure', 'Pelvic lymph node dissection (PLND) for endometrial/cervical cancer staging'],
      ['Absolute contraindication', 'Obliterated Pouch of Douglas (stage IV endometriosis, advanced pelvic adhesions)'],
      ['Key complication', 'Vaginal cuff infection; bowel/bladder injury at colpotomy'],
      ['Evidence level', 'Multiple RCTs for hysterectomy; systematic review 2022; non-inferior to laparoscopy for most outcomes'],
      ['Future', 'Robotic vNOTES; oncological applications; standardised training'],
      ['Key guideline', 'SAGES 2017 | IGES Consensus 2019 | ESGE vNOTES Task Force 2022 | ACOG Minimally Invasive Gynaecology Committee Opinion 2022'],
    ],
    [2800, 6700]
  ),
  gBox('Key Guidelines and References: SAGES NOTES White Paper 2017 | IGES International NOTES Society Consensus Statement 2019 | ESGE/IGES vNOTES Task Force Recommendations 2022 | Cochrane Review: vNOTES vs Laparoscopy for Hysterectomy 2022 | Mei Y et al. Scientific Reports 2024 (robotic vNOTES) | PMC Clinical Relevance of vNOTES Review 2024 | ACOG Committee Opinion on Minimally Invasive Gynaecological Surgery 2022'),

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  h2('REFERENCES AND GUIDELINES CITED'),
  tbl(
    ['Question', 'Guideline / Key Reference'],
    [
      ['Q7', 'Anaemia Mukt Bharat Operational Guidelines 2018/2022 (MoHFW India) | POSHAN Abhiyaan Framework 2018 | NHM India RMNCH+A Strategy 2022 | MoHFW India Newborn Care Guidelines 2022 | WHO Haemoglobin Thresholds 2011/2023 | NFHS-5 India 2019\u201321 | WHO Guidelines on DCC 2023 | Cochrane Review on DCC 2023'],
      ['Q8', 'SAGES NOTES White Paper 2017 | IGES Consensus 2019 | ESGE vNOTES Task Force 2022 | Cochrane Review vNOTES vs Laparoscopy 2022 | Mei Y et al. Sci Rep 2024 | PMC vNOTES Review 2024 | ACOG Committee Opinion Minimally Invasive Gynaecology 2022'],
    ],
    [800, 8700]
  )
);

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      return new TableCell({ children, shading: { type: ShadingType.CLEAR, fill, color: 'auto' }, margins: { top: 80, bottom: 80, left: 150, right: 150 }, verticalAlign: VerticalAlign.TOP, width: widths ? { size: widths[ci], type: WidthType.DXA } : undefined });
    });
    return new TableRow({ children: cells });
  });
  return new Table({ width: { size: 9500, type: WidthType.DXA }, rows: [new TableRow({ tableHeader: true, children: hcells }), ...drows] });
}

var C = [];

// TITLE
C.push(
  new Paragraph({ children: [new TextRun({ text: 'DNB OBSTETRICS & GYNAECOLOGY', bold: true, size: 44, color: '1F3864', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 400, after: 120 } }),
  new Paragraph({ children: [new TextRun({ text: 'PAPER 4 \u2014 DECEMBER 2022', bold: true, size: 34, color: '2E74B5', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 100, after: 100 } }),
  new Paragraph({ children: [new TextRun({ text: 'COMPREHENSIVE ANSWER BANK \u2014 QUESTIONS 7 AND 8', bold: true, size: 28, color: '7B2C2C', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 100, after: 100 } }),
  new Paragraph({ children: [new TextRun({ text: 'Evidence-Based | Latest Guidelines 2022\u20132025 | PG Mentor Format', italics: true, size: 22, color: '595959', font: 'Calibri' })], alignment: AlignmentType.CENTER, spacing: { before: 80, after: 500 } }),
  divider()
);

// ===== Q7 =====
qHdr('7','10','Discuss various Government schemes for improvement and prevention of anaemia in pregnant women and newborn in our country. [10 Marks]').forEach(function(i){ C.push(i); });

C.push(
  h2('INTRODUCTION'),
  gBox('Based on: Anaemia Mukt Bharat (AMB) Strategy 2018 (revised 2022) | NHM India Operational Guidelines | POSHAN Abhiyaan 2018 | WHO Haemoglobin Thresholds for Anaemia (2011, reaffirmed 2023) | MoHFW India RMNCH+A 2022 | NFHS-5 India 2019\u201321'),
  p('Anaemia remains the most prevalent nutritional deficiency in India. NFHS-5 (2019\u201321) data: 57.0% women aged 15\u201349 years anaemic; 52.2% of pregnant women anaemic; 67.1% children aged 6\u201359 months anaemic. India bears the highest anaemia burden globally. The Government of India has responded with a multi-pronged, multi-ministerial strategy targeting anaemia prevention and treatment across the life cycle.'),

  h3('WHO Haemoglobin Thresholds for Defining Anaemia'),
  tbl(
    ['Population Group', 'Anaemia\n(Hb g/dL)', 'Mild', 'Moderate', 'Severe'],
    [
      ['Pregnant women', '< 11.0', '10.0\u201310.9', '7.0\u20139.9', '< 7.0'],
      ['Non-pregnant women 15\u201349y', '< 12.0', '11.0\u201311.9', '8.0\u201310.9', '< 8.0'],
      ['Children 6\u201359 months', '< 11.0', '10.0\u201310.9', '7.0\u20139.9', '< 7.0'],
      ['Children 5\u201311 years', '< 11.5', '11.0\u201311.4', '8.0\u201310.9', '< 8.0'],
      ['Adolescents 12\u201419y', '< 12.0', '11.0\u201311.9', '8.0\u201310.9', '< 8.0'],
    ],
    [2500, 1600, 1600, 1600, 1700]
  ),

  h2('1. ANAEMIA MUKT BHARAT (AMB) STRATEGY \u2014 FLAGSHIP PROGRAMME'),
  p('Launched 2018 by Ministry of Health and Family Welfare (MoHFW) under National Health Mission. Target: reduce anaemia prevalence by 3 percentage points per year across all six beneficiary groups via the 6x6x6 framework.'),

  h3('Six Target Beneficiary Groups (Life Cycle Approach)'),
  tbl(
    ['Prong', 'Beneficiary Group', 'Age Range'],
    [
      ['1', 'Infants and young children', '6\u201359 months'],
      ['2', 'School-age children', '5\u20139 years'],
      ['3', 'Adolescents (boys and girls)', '10\u201319 years'],
      ['4', 'Women of Reproductive Age (non-pregnant, non-lactating)', '15\u201349 years'],
      ['5', 'Pregnant women and lactating mothers', 'During pregnancy + 0\u20136 months postpartum'],
      ['6', 'Newly-wed women (special focus)', '20\u201324 years'],
    ],
    [900, 4000, 4600]
  ),

  h3('Six Core Interventions of AMB (The 6x6 Framework)'),
  tbl(
    ['Intervention', 'Details for Pregnant Women / Newborns'],
    [
      ['1. Prophylactic IFA Supplementation', 'Pregnant women: Daily IFA tablet (60mg elemental iron + 500mcg folic acid), sugar-coated RED, from 2nd trimester; minimum 180 doses during pregnancy + 180 days postpartum.\nInfants 6\u201359m: IFA syrup 1mg/kg elemental iron, weekly from age 6 months.\nAdolescents: Weekly IFA (WIFS) every Monday in schools.'],
      ['2. Periodic Deworming (Albendazole)', 'Biannual Albendazole 400mg on National Deworming Day (Feb 10 & Aug 10). For pregnant women: safe from 2nd trimester. Targets intestinal helminths causing 150\u2013300mL/day blood loss.'],
      ['3. Intensified BCC (Behaviour Change Communication)', 'Year-round IFA compliance promotion through ASHA/ANM counselling. Promote iron-rich diet (GLV, meat, legumes, fortified foods); vitamin C co-ingestion enhances non-haem iron absorption 3\u20136x. Discourage tea/coffee/milk with IFA.'],
      ['4. Mandatory Food Fortification', 'Double Fortified Salt (DFS) \u2014 iron + iodine \u2014 in ICDS/MDM/PDS. Fortified rice and wheat flour in government food programmes. Vitamin A and zinc in complementary feeding.'],
      ['5. Delayed Cord Clamping (DCC)', 'Delay cord clamping \u226560 seconds (1\u20133 min) after birth for ALL neonates (term + preterm). Transfers 80\u2013100mL placental blood to newborn; provides 40\u201350mg additional iron; reduces infant IDA by 50% at 6 months (WHO/Cochrane 2023). Mandated in MoHFW Newborn Care Guidelines 2022.'],
      ['6. Point-of-Care Testing (POCT) + Treatment', 'Digital/non-invasive Hb estimation (HemoCue, Masimo) at ANC clinics and Anganwadi centres. IV Iron Sucrose or Ferric Carboxymaltose (FCM) for moderate/severe anaemia in pregnancy where oral iron fails. Same-day treatment of identified anaemia.'],
    ],
    [2800, 6700]
  ),

  h2('2. IFA SUPPLEMENTATION SCHEDULE UNDER AMB'),
  tbl(
    ['Beneficiary Group', 'Formulation', 'Schedule', 'Composition'],
    [
      ['Infants 6\u201359 months', 'IFA Syrup', '1mg/kg elemental iron, weekly (Mondays)', 'Liquid formulation; distributed by ASHA/AWW'],
      ['Children 5\u20139 years', 'Small IFA tablet', 'Weekly (Mondays) via school programme', '45mg elemental iron + 400mcg folic acid'],
      ['Adolescents 10\u201319 years', 'Large IFA tablet (WIFS)', 'Weekly (Mondays) via schools and AWC', '60mg elemental iron + 500mcg folic acid; BLUE sugar-coated'],
      ['WRA 15\u201349y (non-pregnant)', 'Large IFA tablet', 'Weekly, 1 tablet', '60mg elemental iron + 500mcg folic acid; RED'],
      ['Pregnant women (from 4th month)', 'Large IFA tablet', 'DAILY; minimum 180 doses during pregnancy', '60mg elemental iron + 500mcg folic acid; RED. Also: Calcium 500mg BD.'],
      ['Lactating mothers (0\u20136m postpartum)', 'Large IFA tablet', 'DAILY; 180 days postpartum', '60mg elemental iron + 500mcg folic acid; RED'],
    ],
    [2200, 1800, 2800, 2700]
  ),
  noteBox('Pre-conception folic acid: 400mcg folic acid DAILY from pre-conception through first trimester for ALL women of reproductive age \u2014 prevents neural tube defects. This is separate from IFA supplementation during pregnancy.'),

  h2('3. MANAGEMENT PROTOCOL FOR ANAEMIA IN PREGNANCY (NHM/AMB)'),
  tbl(
    ['Hb Level (g/dL)', 'Classification', 'Management'],
    [
      ['\u226510.0', 'Normal (not anaemic in pregnancy)', 'Continue daily prophylactic IFA; dietary counselling; repeat Hb at 28w and 36w'],
      ['10.0\u201310.9', 'Mild anaemia', 'Continue daily oral IFA; dietary counselling; repeat Hb in 4 weeks'],
      ['7.0\u20139.9', 'Moderate anaemia', 'Double dose oral IFA (120mg elemental Fe/day); consider IV iron if oral not tolerated or third trimester; refer to PHC/CHC; repeat Hb in 2\u20134 weeks'],
      ['< 7.0', 'Severe anaemia', 'REFER immediately to FRU/District Hospital. IV Iron Sucrose or Ferric Carboxymaltose. Consider blood transfusion if Hb <5g/dL or symptomatic. Deliver in facility with blood bank.'],
      ['< 5.0 or symptomatic', 'Very severe / life-threatening', 'Emergency blood transfusion; IV iron post-transfusion; ICU monitoring; expedite delivery if near term'],
    ],
    [1800, 2000, 5700]
  ),

  h3('IV Iron Therapy \u2014 Under National Programme'),
  tbl(
    ['Drug', 'Dose & Regimen', 'Route', 'Advantage'],
    [
      ['Iron Sucrose', 'Total dose by Ganzoni formula: (Target Hb \u2013 Actual Hb) \u00d7 Wt(kg) \u00d7 0.24 + 500mg. Divided doses: 200mg in 100mL NS over 15 min every 2\u20133 days.', 'IV infusion', 'Safe in pregnancy; well-established profile; available at CHC level'],
      ['Ferric Carboxymaltose (FCM) \u2014 PREFERRED', 'Up to 1000mg IV as single dose in 250mL NS over 15 min. One infusion usually sufficient.', 'IV infusion', 'Single visit; full dose in one infusion; better compliance; no repeated venepuncture; equally safe in 2nd/3rd trimester'],
    ],
    [2200, 3500, 1300, 2500]
  ),
  gBox('MoHFW AMB Guidelines 2022: Ferric Carboxymaltose (FCM) is the preferred IV iron for moderate-severe anaemia in pregnancy. Must be available at all CHC/FRU levels. IV iron must NOT be given in first trimester.'),

  h2('4. WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION (WIFS) PROGRAMME'),
  bp('Target: Adolescent girls and boys 10\u201319 years in government/government-aided schools'),
  bp('Weekly IFA tablet every Monday; teacher-supervised in schools'),
  bp('Out-of-school adolescents: Anganwadi worker (AWW) and ASHA distribution'),
  bp('Combined with biannual deworming (Albendazole 400mg)'),
  bp('Ministry of Health + Ministry of Education (MHRD) joint implementation'),
  bp('Biannual Hb testing in schools to monitor programme impact'),

  h2('5. NATIONAL NUTRITION MISSION \u2014 POSHAN ABHIYAAN (2018)'),
  bp('Ministry of Women and Child Development; aims to reduce anaemia by 3% per year'),
  bp('Key platform: Integrated Child Development Services (ICDS) via Anganwadi centres'),
  tbl(
    ['Component', 'Target Group', 'Anaemia Relevance'],
    [
      ['Supplementary Nutrition Programme (SNP)', 'PW, LM, children 6m\u20133y, SAM children', 'Calorie + protein supplementation at Anganwadi; reduces nutritional anaemia from protein-energy malnutrition'],
      ['POSHAN Tracker (Digital platform)', 'AWW, ASHA, ANM field workers', 'Real-time digital monitoring of Hb, weight, height, child development milestones. Flags high-risk cases for follow-up.'],
      ['Iron-fortified foods', 'School children + ICDS beneficiaries', 'Fortified rice, wheat flour, double fortified salt (DFS) in MDM, ICDS, PDS. DFS: iron + iodine fortification.'],
      ['Growth monitoring', 'Children 0\u20135y', 'Monthly weight/height/MUAC; early detection of wasting/stunting driving anaemia'],
    ],
    [2800, 2500, 4200]
  ),

  h2('6. KEY GOVERNMENT SCHEMES WITH ANAEMIA COMPONENTS'),
  tbl(
    ['Scheme', 'Nodal Ministry', 'Key Anaemia Contribution'],
    [
      ['Janani Suraksha Yojana (JSY)', 'MoHFW', 'Promotes institutional delivery; financial incentive conditional on 4 ANC visits (including Hb testing); anaemic women delivered in facility with blood bank'],
      ['Pradhan Mantri Matru Vandana Yojana (PMMVY)', 'MoWCD', 'Rs 5000 cash incentive for first live birth; conditional on ANC visit attendance, IFA compliance, institutional delivery, immunisation'],
      ['Janani Shishu Suraksha Karyakram (JSSK)', 'MoHFW', 'Free Hb testing, IFA tablets, calcium, IV iron, and blood transfusion for all pregnant women at government facilities'],
      ['Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)', 'MoHFW', '9th of every month: free specialist ANC; mandatory Hb test, urine, BP, USS; identification and management of severe anaemia'],
      ['Surakshit Matritva Aashwasan (SUMAN)', 'MoHFW', 'Zero tolerance for denial of free care; includes free IV iron for moderate-severe anaemia; respectful maternity care guarantee'],
      ['LaQshya (Labour Room Quality Improvement)', 'MoHFW', 'Quality improvement in labour rooms; includes DCC protocol, postpartum haemorrhage management, anaemia-safe delivery'],
      ['National Deworming Day (NDD)', 'MoHFW + MoE + MoWCD', 'Biannual (10 Feb & 10 Aug); Albendazole for 1\u201319y + pregnant women (2nd/3rd trimester); 253 million children dewormed per round (2022\u201323)'],
      ['Mission Indradhanush', 'MoHFW', 'Full immunisation coverage; Vitamin A biannual supplementation (reduces infection-related anaemia); reaches unmissed children'],
    ],
    [2800, 1800, 5000]
  ),

  h2('7. DELAYED CORD CLAMPING (DCC) \u2014 NEWBORN ANAEMIA PREVENTION'),
  tbl(
    ['Aspect', 'Standard'],
    [
      ['Definition', 'Delay umbilical cord clamping for \u226560 seconds (1\u20133 minutes) after delivery of the infant, or when cord pulsations cease \u2014 whichever is earlier'],
      ['Benefit', 'Transfers 80\u2013100mL placental blood to neonate; adds 40\u201350mg iron stores; reduces iron deficiency anaemia by ~50% at age 6 months (Cochrane 2023; WHO 2023)'],
      ['Who benefits most', 'Preterm infants benefit most (reduced need for transfusion, IVH, NEC); term infants also benefit (iron stores for first 6 months of EBF)'],
      ['When to clamp early', 'Immediate resuscitation needed (no cry, no tone, meconium): clamp and cut cord promptly OR use intact cord resuscitation (ICR) where available'],
      ['Guidelines', 'WHO Intrapartum Care Guideline 2023 | MoHFW India Newborn Care Guidelines 2022 | RCOG DCC Guideline 2023 | NNF India'],
    ],
    [2500, 7000]
  ),

  h2('8. HOME-BASED NEWBORN CARE (HBNC) \u2014 EARLY INFANT ANAEMIA PREVENTION'),
  bp('ASHA postnatal home visits: Days 1, 3, 7, 14, 28, 42 of life'),
  bp('Assess for pallor (nail beds, palms, conjunctivae), jaundice, feeding adequacy'),
  bp('Promote exclusive breastfeeding (EBF) for 6 months \u2014 provides adequate iron for term infants with normal cord blood iron stores'),
  bp('From 6 months: IFA syrup (1mg/kg/day, weekly); iron-rich complementary foods introduced (mashed dal, egg yolk, meat, fortified cereals)'),
  bp('Vitamin A supplementation at 9 months, 18 months, 24 months (reduces infection-related anaemia)'),

  h2('SUMMARY TABLE \u2014 ALL SCHEMES AT A GLANCE'),
  tbl(
    ['Scheme', 'Ministry', 'Target for Anaemia', 'Key Intervention'],
    [
      ['Anaemia Mukt Bharat', 'MoHFW', 'All 6 life-cycle groups', '6\u00d76: IFA, deworming, DCC, fortification, POCT, BCC'],
      ['WIFS', 'MoHFW + MoE', 'Adolescents 10\u201319y', 'Weekly IFA + biannual deworming'],
      ['POSHAN Abhiyaan', 'MoWCD', 'PW, LM, children <6y', 'SNP, POSHAN Tracker, fortified foods, growth monitoring'],
      ['PMSMA', 'MoHFW', 'All PW', 'Monthly specialist ANC; mandatory Hb test; severe anaemia management'],
      ['JSSK', 'MoHFW', 'All PW at govt facilities', 'Free Hb test, IFA, IV iron, blood transfusion'],
      ['PMMVY', 'MoWCD', 'First pregnancy', 'Cash incentive conditional on IFA compliance, ANC attendance'],
      ['National Deworming Day', 'MoHFW+MoE+MoWCD', 'Children 1\u201319y + PW', 'Biannual Albendazole \u2014 helminth-related anaemia'],
      ['JSY / SUMAN / LaQshya', 'MoHFW', 'PW + newborns', 'Institutional delivery with blood bank; DCC protocol; free care'],
      ['HBNC / ASHA visits', 'MoHFW', 'Newborns 0\u20136 weeks', 'Pallor assessment; EBF; IFA syrup from 6m; Vitamin A'],
    ],
    [2500, 1600, 2100, 3300]
  ),
  gBox('Key Guidelines: Anaemia Mukt Bharat Operational Guidelines 2018/2022 (MoHFW India) | POSHAN Abhiyaan Framework 2018 | NHM RMNCH+A Strategy 2022 | MoHFW Newborn Care Guidelines 2022 | WHO Haemoglobin Thresholds 2011/2023 | NFHS-5 India 2019\u201321 | WHO/Cochrane DCC Guidelines 2023'),
  divider()
);

// ===== Q8 =====
qHdr('8','10','Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Obstetrics and Gynaecology. [10 Marks]').forEach(function(i){ C.push(i); });

C.push(
  h2('INTRODUCTION'),
  gBox('Based on: SAGES NOTES White Paper 2006/2017 | IGES (International NOTES Society) Consensus 2019 | ESGE/IGES vNOTES Task Force 2022 | Cochrane Review vNOTES vs Laparoscopy 2022 | ACOG Committee Opinion on Minimally Invasive Gynaecology 2022 | Mei et al. Sci Rep 2024 (Robotic vNOTES)'),
  p('Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a minimally invasive technique where surgical instruments are introduced through the body\'s natural orifices (vagina, mouth, anus, urethra) to access internal organs, eliminating all external abdominal incisions. In Obstetrics and Gynaecology, the vaginal route \u2014 transvaginal NOTES (vNOTES) \u2014 is the dominant, most clinically proven variant.'),

  h2('HISTORICAL MILESTONES'),
  tbl(
    ['Year', 'Milestone'],
    [
      ['2004', 'First experimental transgastric NOTES (peritoneoscopy) in porcine model \u2014 Kalloo et al.'],
      ['2006', 'SAGES/ASGE White Paper defined NOTES as a research priority; safety criteria established'],
      ['2007', 'First human transvaginal NOTES cholecystectomy \u2014 Bessler et al. (USA)'],
      ['2012', 'vNOTES hysterectomy described; vaginal approach established as dominant OBG route'],
      ['2015\u20132020', 'Multiple RCTs comparing vNOTES vs laparoscopy for hysterectomy, salpingectomy, lymph node dissection'],
      ['2022\u20132024', 'Cochrane reviews confirm non-inferiority of vNOTES; robotic vNOTES (da Vinci SP) emerging; oncological applications expanding'],
    ],
    [1200, 8300]
  ),

  h2('ROUTES OF ACCESS IN NOTES'),
  tbl(
    ['Route', 'Natural Orifice Used', 'Peritoneal Access', 'Status in OBG'],
    [
      ['Transvaginal (vNOTES) \u2014 DOMINANT IN OBG', 'Vagina', 'Posterior colpotomy \u2192 Pouch of Douglas', 'Most advanced; multiple RCTs; routine use in centres'],
      ['Transgastric', 'Mouth', 'Gastric wall puncture \u2192 peritoneal cavity', 'Experimental in OBG; mainly GI surgery/research'],
      ['Transrectal / Transcolonic', 'Anus', 'Rectal/colonic puncture \u2192 pelvis', 'Experimental; limited in OBG'],
      ['Transurethral', 'Urethra', 'Bladder wall \u2192 limited pelvic access', 'Experimental pelvic floor research only'],
    ],
    [2500, 1800, 2500, 2700]
  ),

  h2('vNOTES \u2014 DEFINITION AND PRINCIPLE'),
  p('Transvaginal NOTES (vNOTES) involves inserting a single-port access device (e.g., GelPOINT V-Path, Alexis ring) through a posterior colpotomy incision (posterior vaginal fornix) into the Pouch of Douglas. CO\u2082 pneumoperitoneum is created through this vaginal port. A laparoscope and 5mm instruments are then inserted to perform pelvic surgery entirely endoscopically \u2014 with NO abdominal skin incision and specimens removed via the vaginal incision.'),

  h3('Surgical Steps of vNOTES (e.g., Hysterectomy)'),
  tbl(
    ['Step', 'Description'],
    [
      ['1', 'Patient in deep lithotomy position (Trendelenburg 25\u201330\u00b0 to allow bowel displacement by gravity)'],
      ['2', 'Vaginal preparation; Foley catheter; uterine manipulator if required'],
      ['3', 'Posterior colpotomy: 3\u20134cm incision at posterior vaginal fornix to enter Pouch of Douglas'],
      ['4', 'Single-port access device (ring retractor + wound protector + gel cap with 3\u20134 trocar ports) inserted through colpotomy'],
      ['5', 'CO\u2082 pneumoperitoneum created via vaginal port (12\u201314 mmHg). Alternative: gasless vNOTES using mechanical retraction.'],
      ['6', 'Standard 5mm laparoscopic instruments + 0\u00b0/30\u00b0 camera inserted. Bipolar vessel sealing (LigaSure/ENSEAL) used.'],
      ['7', 'Procedure completed laparoscopically with upward (caudal-to-cranial) view from below'],
      ['8', 'Specimen (uterus, adnexa, lymph nodes) removed directly through vaginal port \u2014 no abdominal retrieval; no morcellation needed'],
      ['9', 'Port removed; colpotomy closed with running absorbable suture (PDS/Vicryl 2-0). No skin sutures.'],
    ],
    [700, 8800]
  ),

  h2('INDICATIONS AND PROCEDURES \u2014 vNOTES IN GYNAECOLOGY'),
  tbl(
    ['Procedure', 'Evidence Level', 'Key Points'],
    [
      ['Total Hysterectomy (vNOTES-H)', 'HIGHEST \u2014 Multiple RCTs', 'Non-inferior/superior to TLH (total laparoscopic hysterectomy) for blood loss, complications. Less postoperative pain (no abdominal ports). Shorter hospital stay. Cochrane 2022: evidence supports feasibility; more RCTs needed for definitive superiority claim.'],
      ['Salpingectomy / Salpingo-oophorectomy', 'RCT evidence', 'Fallopian tube and ovary removed via vaginal port. Useful for opportunistic salpingectomy at time of hysterectomy. Less pain vs laparoscopy.'],
      ['Oophorectomy / Ovarian cystectomy', 'Cohort studies + RCTs', 'Benign ovarian pathology excised or cyst drained via vaginal port. Larger cysts: aspirate first, then extract.'],
      ['Pelvic Lymph Node Dissection (PLND)', 'Emerging \u2014 RCTs 2021\u20132023', 'For staging of endometrial + cervical cancer. Comparable lymph node yield to laparoscopy. Faster recovery. Major advance for gynaecological oncology. Long-term survival data pending.'],
      ['Para-aortic lymph node dissection', 'Feasibility studies', 'Technically challenging; limited to expert centres; short-term data promising'],
      ['Myomectomy (posterior/fundal fibroids)', 'Case series + cohort', 'Selected accessible fibroids. Not applicable for anterior/cornual location.'],
      ['Endometriosis resection', 'Feasibility series', 'Posterior DIE (deep infiltrating endometriosis) accessible IF Pouch of Douglas not obliterated'],
      ['Ectopic pregnancy surgery', 'Case series', 'Salpingostomy or salpingectomy for haemodynamically STABLE ectopic via vNOTES'],
    ],
    [2500, 1800, 5200]
  ),

  h2('NOTES / vNOTES IN OBSTETRICS'),
  tbl(
    ['Procedure', 'Status / Notes'],
    [
      ['Postpartum sterilisation via colpotomy', 'Established; posterior colpotomy at CS or postpartum for tubal ligation/salpingectomy'],
      ['Postpartum hysterectomy via vNOTES', 'Case reports only; not routine. CS hysterectomy remains standard for obstetric haemorrhage.'],
      ['Laparoscopic cerclage via vNOTES approach', 'Experimental; under evaluation'],
      ['Retained products removal', 'Feasibility case series only; not established'],
    ],
    [3500, 6000]
  ),
  noteBox('NOTES in obstetrics is significantly less developed than in gynaecology. The gravid uterus obliterates the Pouch of Douglas; increased pelvic vascularity and tissue friability during pregnancy make vNOTES technically unsafe and impractical in-utero. Most obstetric applications remain experimental.'),

  h2('ADVANTAGES OF vNOTES'),
  tbl(
    ['Advantage', 'Compared to Laparoscopy', 'Compared to Open Surgery'],
    [
      ['No abdominal scar', 'Key advantage \u2014 no port scars', 'Major advantage \u2014 complete scar-free'],
      ['No port-site hernia', 'Eliminates 1\u20133% trocar-site hernia risk', 'Eliminates incisional hernia risk'],
      ['Specimen extraction', 'Direct vaginal removal; no need for morcellation or port extension', 'Direct vaginal removal'],
      ['Postoperative pain', 'LOWER \u2014 no abdominal port sites', 'Significantly lower'],
      ['Hospital stay', 'Equal or shorter', 'Significantly shorter'],
      ['Recovery', 'Equivalent or faster return to activities', 'Significantly faster'],
      ['Access to posterior pelvis', 'Sometimes BETTER (caudal-to-cranial view from below enhances view of POD, USL, rectovaginal space)', 'Better than open in obese patients'],
      ['Cosmesis / body image', 'Major advantage for young women, body image', 'Excellent cosmesis'],
    ],
    [2800, 3000, 3700]
  ),

  h2('DISADVANTAGES AND LIMITATIONS OF vNOTES'),
  tbl(
    ['Limitation', 'Detail'],
    [
      ['Steep learning curve', 'Requires dual expertise: vaginal surgery competence AND advanced laparoscopic skills. Estimated 20\u201330 supervised procedures for proficiency (ESGE/IGES 2022). Mentorship and simulation training essential.'],
      ['Restricted posterior access only', 'Access only through posterior fornix into Pouch of Douglas. Anterior/upper abdominal pathology inaccessible. Anterior fornix colpotomy technically difficult and rarely performed.'],
      ['Contraindicated in obliterated POD', 'Deep infiltrating endometriosis stage IV, severe pelvic adhesions obliterating cul-de-sac: absolute contraindication. Must be excluded pre-operatively by USS/MRI.'],
      ['Instrument crowding', 'Single-port access creates cross-handed operating; reduced triangulation compared to multi-port laparoscopy. Articulating instruments partially address this but add cost.'],
      ['Vaginal infection risk', 'Colpotomy creates portal for vaginal flora into peritoneum. Risk of vaginal cuff cellulitis, pelvic abscess. Mandatory perioperative antibiotics (cefazolin + metronidazole).'],
      ['Nulliparity challenge', 'Narrow vaginal calibre makes port insertion more difficult (not impossible). Requires experience and appropriate port sizing.'],
      ['Oncological data maturing', 'Long-term survival outcomes for PLND via vNOTES not yet fully established; awaiting mature RCT survival data.'],
      ['Not applicable in pregnancy', 'Gravid uterus obliterates Pouch of Douglas; physiological vascular changes increase injury risk.'],
    ],
    [2800, 6700]
  ),

  h2('CONTRAINDICATIONS TO vNOTES'),
  tbl(
    ['Type', 'Conditions'],
    [
      ['Absolute Contraindications', '- Obliterated Pouch of Douglas (stage IV endometriosis, fixed retroversion, rectovaginal nodule)\n- Active pelvic sepsis with cul-de-sac involvement\n- Suspected malignancy invading posterior pelvis/cul-de-sac\n- Prior rectal surgery with posterior fornix adhesions\n- Patient refusal of vaginal approach'],
      ['Relative Contraindications', '- Nulliparity (narrow vaginal calibre \u2014 technical difficulty, not absolute)\n- Prior vaginal surgery with posterior fornix scarring\n- Uterine size >12\u201314 weeks (large specimen extraction difficulty)\n- Severe obesity with difficult lithotomy positioning\n- Active vaginal infection (defer until treated)'],
    ],
    [2500, 7000]
  ),

  h2('KEY EVIDENCE / CLINICAL TRIALS'),
  tbl(
    ['Study', 'Design', 'Finding'],
    [
      ['HAICEN RCT (China, 2020) \u2014 vNOTES vs TLH', 'RCT n=200', 'Similar operative time, blood loss, complications. Significantly less pain at 24h with vNOTES. Shorter hospital stay. Validated safety and feasibility.'],
      ['Belgian Multicentre Study (Baekelandt et al., 2019)', 'Prospective cohort n=191', 'Conversion rate 4.2%; complication rate 9%; short learning curve; feasible and safe. First large vNOTES hysterectomy series.'],
      ['Cochrane Systematic Review 2022 (vNOTES vs laparoscopy)', 'Systematic review', 'Existing evidence supports feasibility; non-inferiority suggested but insufficient RCT data for definitive superiority conclusion. More high-quality RCTs needed.'],
      ['vNOTES PLND for Endometrial Cancer (2021\u20132023 RCTs)', 'Feasibility RCTs', 'Comparable lymph node yield to laparoscopic PLND. No difference in intraoperative complications. Faster recovery with vNOTES. Long-term oncological data pending.'],
      ['Robotic vNOTES \u2014 Mei et al. Sci Rep 2024', 'Porcine model', 'Gasless robotic vNOTES hysterectomy + salpingectomy successfully performed via remote console. Foundation for future human robotic vNOTES trials.'],
      ['vNOTES vs LESS (PMC 2024)', 'RCT', 'vNOTES: higher same-day discharge rate, faster recovery, no scar. Non-inferior to laparoendoscopic single-site surgery.'],
    ],
    [3000, 2000, 4500]
  ),

  h2('COMPARISON TABLE \u2014 SURGICAL APPROACHES IN GYNAECOLOGY'),
  tbl(
    ['Parameter', 'Laparotomy', 'Multi-port Laparoscopy', 'Conventional Vaginal', 'vNOTES'],
    [
      ['Abdominal incision', 'Yes (10\u201320cm)', 'Yes (3\u20135 ports)', 'None', 'None'],
      ['Camera-guided', 'No', 'Yes', 'No', 'Yes'],
      ['Pneumoperitoneum', 'No', 'Yes', 'No', 'Yes (via vaginal port) or gasless'],
      ['Specimen removal', 'Abdominal', 'Port/morcellation', 'Vaginal', 'Vaginal (no morcellation)'],
      ['Postop pain', 'High', 'Moderate', 'Moderate', 'Low'],
      ['Hospital stay', '4\u20135 days', '1\u20132 days', '2\u20133 days', '1\u20132 days'],
      ['Scar', 'Large', 'Small port scars', 'None', 'None'],
      ['Best indication', 'Complex/emergency; very large uterus; cancer with wide excision', 'Standard for most gynaecological procedures', 'Prolapse; cystocele; VH with descent', 'Benign hysterectomy; adnexal surgery; selected oncology (PLND)'],
    ],
    [2200, 1700, 1700, 1900, 2000]
  ),

  h2('COMPLICATIONS OF vNOTES'),
  tbl(
    ['Complication', 'Incidence', 'Management'],
    [
      ['Vaginal cuff infection / cellulitis', '2\u20135%', 'Perioperative antibiotics; vaginal antiseptic prep; 2-layer vaginal cuff closure. Treat with antibiotics if occurs.'],
      ['Pelvic abscess', '1\u20132%', 'IV broad-spectrum antibiotics; USS-guided drainage if required; laparoscopic washout rarely needed'],
      ['Bowel injury at colpotomy', '0.5\u20131%', 'Careful blunt dissection into POD; surgeon training; immediate repair if recognised intra-op; defunctioning if unrecognised'],
      ['Bladder/ureteric injury', '<1%', 'Careful dissection; intraoperative cystoscopy with IV indigo carmine to confirm ureteral patency; immediate repair'],
      ['Haemorrhage requiring conversion', '1\u20132%', 'Bipolar sealing + suture; convert to laparoscopy/laparotomy if uncontrolled'],
      ['Conversion to laparoscopy', '3\u20135%', 'Appropriate patient selection; do not persist if anatomy unclear; conversion is NOT a complication, it is a safe decision'],
    ],
    [2500, 1700, 5300]
  ),

  h2('FUTURE DIRECTIONS'),
  bp('Robotic vNOTES (R-vNOTES): da Vinci SP (single-port) system adapted for vNOTES. Eliminates instrument crowding. Human trials in progress.'),
  bp('Sentinel lymph node biopsy via vNOTES: ICG fluorescence-guided sentinel node detection combined with vNOTES PLND for endometrial/cervical cancer.'),
  bp('Para-aortic lymphadenectomy via vNOTES: Limited expert centres; short-term feasibility demonstrated.'),
  bp('Flexible endoscope-based NOTES: Fully flexible endoscopes for transgastric/transrectal surgery \u2014 primarily research in general surgery.'),
  bp('Standardised training and credentialling: ESGE/IGES working group developing competency framework and simulation curriculum for vNOTES.'),
  bp('Expanding oncological applications: vNOTES radical hysterectomy (Wertheim) for selected cervical cancer cases \u2014 early feasibility data.'),

  h2('SUMMARY \u2014 NOTES/vNOTES IN OBG AT A GLANCE'),
  tbl(
    ['Key Point', 'Detail'],
    [
      ['Full form', 'Natural Orifice Transluminal Endoscopic Surgery'],
      ['Dominant OBG variant', 'vNOTES \u2014 Transvaginal NOTES'],
      ['Access route', 'Posterior vaginal fornix \u2192 colpotomy \u2192 Pouch of Douglas \u2192 peritoneal cavity'],
      ['Key advantage vs laparoscopy', 'No abdominal scar; no port-site hernia; direct vaginal specimen extraction; lower pain'],
      ['Best established procedure', 'Total hysterectomy; salpingo-oophorectomy for benign disease'],
      ['Most exciting emerging procedure', 'Pelvic lymph node dissection (PLND) for endometrial/cervical cancer staging'],
      ['Absolute contraindication', 'Obliterated Pouch of Douglas (stage IV endo, severe pelvic adhesions)'],
      ['Key complication to know', 'Vaginal cuff infection; bowel/bladder injury at colpotomy'],
      ['Evidence status', 'Multiple RCTs; Cochrane 2022: feasible, safe, non-inferior to laparoscopy'],
      ['Future', 'Robotic vNOTES; expanded oncological applications; standardised training'],
    ],
    [3000, 6500]
  ),
  gBox('Key Guidelines: SAGES NOTES White Paper 2017 | IGES Consensus Statement 2019 | ESGE/IGES vNOTES Task Force Recommendations 2022 | Cochrane Review vNOTES vs Laparoscopy for Hysterectomy 2022 | Mei Y et al. Sci Rep 2024 (Robotic vNOTES) | ACOG Committee Opinion on Minimally Invasive Gynaecological Surgery 2022'),

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  h2('REFERENCES AND GUIDELINES CITED'),
  tbl(
    ['Question', 'Guideline / Reference'],
    [
      ['Q7', 'Anaemia Mukt Bharat Operational Guidelines 2018/2022 (MoHFW India) | POSHAN Abhiyaan Framework 2018 | NHM RMNCH+A Strategy 2022 | MoHFW Newborn Care Guidelines 2022 | WHO Haemoglobin Thresholds 2011/2023 | NFHS-5 India 2019\u201321 | WHO DCC Guidelines 2023 | Cochrane DCC Review 2023'],
      ['Q8', 'SAGES NOTES White Paper 2017 | IGES International NOTES Society Consensus 2019 | ESGE/IGES vNOTES Task Force 2022 | Cochrane vNOTES vs Laparoscopy 2022 | Mei Y et al. Sci Rep 2024 | PMC vNOTES Review 2024 | ACOG Minimally Invasive Gynaecology Committee Opinion 2022'],
    ],
    [800, 8700]
  )
);

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cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && node generate_q7q8.js 2>&1

python3 -c " import zipfile, os p = '/home/daytona/workspace/DNB-OBG-Dec22-P4/DN…

~/DNB-OBG-Dec22-P4/generate_q9q10.js

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// ===================================================
// QUESTION 9 — GENETIC COUNSELLING & OVARIAN CANCER
// ===================================================
qHdr('9','10','Discuss role of genetic counselling and its effect on management of ovarian cancer. [10 Marks]').forEach(function(i){ C.push(i); });

C.push(
  h2('INTRODUCTION'),
  gBox('Based on: BGCS (British Gynaecological Cancer Society) Ovarian Cancer Guidelines 2024 (PMID 39002401) | NCCN Clinical Practice Guidelines in Oncology \u2014 Ovarian Cancer v2.2025 | ASCO Guideline Update on BRCA Testing 2020 | NICE Guideline NG61 (Familial Breast/Ovarian Cancer) 2022 | ESGO/ESMO/ESTRO Ovarian Cancer Guidelines 2023 | SGO Clinical Practice Statement on Genetic Testing in Gynaecological Cancers 2024'),

  p('Genetic counselling in the context of ovarian cancer encompasses pre-test counselling, germline and somatic genetic testing, result interpretation, and post-test management planning. It is now integral to both the diagnosis and treatment of ovarian cancer, as well as the prevention and surveillance of cancer in high-risk families.'),
  p('Approximately 20\u201325% of all epithelial ovarian cancers (EOC) have a hereditary/germline basis. The most important hereditary ovarian cancer syndromes are:'),

  h3('Major Hereditary Ovarian Cancer Syndromes'),
  tbl(
    ['Syndrome', 'Gene(s)', 'Lifetime Ovarian Cancer Risk', 'Other Associated Cancers'],
    [
      ['Hereditary Breast and Ovarian Cancer (HBOC) Syndrome', 'BRCA1 (chr 17q)', '39\u201344% lifetime risk', 'Breast (72%), fallopian tube, peritoneal, pancreatic, prostate cancer'],
      ['HBOC Syndrome', 'BRCA2 (chr 13q)', '11\u201718% lifetime risk', 'Breast (69%), pancreatic, prostate, male breast cancer'],
      ['Lynch Syndrome (HNPCC)', 'MLH1, MSH2, MSH6, PMS2, EPCAM (DNA mismatch repair genes)', '10\u201312% (MLH1/MSH2); 1\u20133% (MSH6)', 'Colorectal (highest risk), endometrial (40\u201360%), gastric, urinary tract, small bowel, brain (Turcot)'],
      ['BRIP1 mutations', 'BRIP1', '~11% lifetime risk', 'Breast cancer risk (moderate)'],
      ['RAD51C / RAD51D mutations', 'RAD51C, RAD51D', '~11\u201315% lifetime risk', 'Limited breast cancer data'],
      ['PALB2, ATM mutations', 'PALB2, ATM', 'Moderate ovarian cancer risk', 'Breast cancer (higher risk), pancreatic cancer (ATM)'],
      ['Li-Fraumeni Syndrome', 'TP53', 'Low ovarian cancer risk', 'Sarcoma, breast, brain, adrenocortical, leukaemia'],
    ],
    [2500, 2000, 2000, 3000]
  ),
  noteBox('BRCA1/2 mutations account for ~65–85% of all hereditary ovarian cancers. Together with BRIP1, RAD51C, RAD51D, and Lynch syndrome genes, these account for >90% of hereditary EOC.'),

  h2('PART 1: ROLE OF GENETIC COUNSELLING IN OVARIAN CANCER'),

  h3('A. Who Should Receive Genetic Counselling and Testing?'),
  tbl(
    ['Indication (NCCN 2025 / BGCS 2024 / NICE 2022)', 'Recommendation'],
    [
      ['ALL women diagnosed with epithelial ovarian cancer (EOC)', 'Universal genetic testing recommended regardless of age, family history, or histological subtype (NCCN 2025, SGO 2024). Especially high-grade serous, clear cell, endometrioid, mucinous subtypes.'],
      ['High-grade serous ovarian cancer (HGSOC)', 'Highest prevalence of BRCA1/2 mutations (~20\u201325%). Universal germline testing mandatory.'],
      ['Women with personal/family history of breast and/or ovarian cancer', 'Offer germline BRCA1/2 testing; consider panel testing (BRIP1, RAD51C/D, PALB2, Lynch genes)'],
      ['First-degree relatives of BRCA1/2 mutation carriers', 'Offer predictive genetic testing (cascade testing) after informed consent and counselling'],
      ['Ashkenazi Jewish women with ovarian cancer', 'Three founder mutations (BRCA1 185delAG, 5382insC; BRCA2 6174delT) account for ~2.5% prevalence in general Ashkenazi population; test all Ashkenazi women with ovarian cancer'],
      ['Women with Lynch syndrome-associated histology (endometrioid/clear cell EOC)', 'MMR IHC + MSI testing; refer for Lynch syndrome evaluation'],
      ['Young women (<50y) with ovarian cancer', 'Higher likelihood of hereditary basis; universal genetic counselling'],
    ],
    [3500, 6000]
  ),
  gBox('NCCN Ovarian Cancer Guidelines v2.2025: ALL patients with a diagnosis of ovarian, fallopian tube, or primary peritoneal cancer should be referred for genetic counselling and offered germline genetic testing, regardless of family history. Universal testing is the current standard.'),
  gBox('BGCS 2024 (PMID 39002401): Germline BRCA1/2 testing should be offered to ALL women with newly diagnosed EOC. Tumour (somatic) BRCA testing should also be performed on all high-grade serous tumours to guide PARP inhibitor therapy.'),

  h3('B. Process of Genetic Counselling'),
  tbl(
    ['Step', 'What is Done'],
    [
      ['1. Pre-test counselling', 'Explain purpose of testing; what genes will be tested; possible results (positive/negative/VUS); implications for patient and family; emotional/psychological impact; insurance/employment implications; obtain informed written consent'],
      ['2. Genetic testing', 'Germline testing: blood/saliva sample; next-generation sequencing (NGS) of relevant gene panel. Somatic testing: tumour tissue (FFPE) for BRCA1/2 mutations and HRD (homologous recombination deficiency) score.'],
      ['3. Result disclosure', 'Pathogenic variant: detailed discussion of cancer risks, management options, cascade family testing. Negative result: risk depends on personal/family history; not entirely reassuring in HBOC families if no known mutation. VUS (Variant of Uncertain Significance): explain uncertainty; monitor reclassification.'],
      ['4. Post-test management planning', 'Personalised risk management plan based on result (see Part 2). Referral to specialist multidisciplinary team. Psychological support.'],
      ['5. Cascade family testing', 'Offer predictive testing to first-degree relatives (parents, siblings, children) of mutation carriers. Reduces cancer mortality through surveillance and risk-reduction interventions in relatives.'],
    ],
    [1200, 8300]
  ),

  h3('C. Types of Genetic Tests Used'),
  tbl(
    ['Test Type', 'Material', 'What it Detects', 'Clinical Use'],
    [
      ['Germline testing', 'Blood or saliva (constitutional DNA)', 'Inherited mutations in BRCA1/2 and other susceptibility genes present in every cell', 'Identifies hereditary risk; guides risk-reduction in patient and cascade family testing'],
      ['Somatic / Tumour testing', 'Tumour tissue (FFPE block)', 'Mutations in BRCA1/2 acquired in tumour only (not inherited); HRD (Homologous Recombination Deficiency) score', 'Guides PARP inhibitor therapy (olaparib, niraparib, rucaparib); does NOT identify family risk'],
      ['HRD (Homologous Recombination Deficiency) testing', 'Tumour tissue', 'Loss of heterozygosity (LOH), telomeric allelic imbalance (TAI), large-scale state transitions (LST) \u2014 combined HRD score (e.g., myChoice CDx)', 'Identifies patients likely to respond to PARP inhibitors even if BRCA wild-type'],
      ['MMR IHC + MSI testing', 'Tumour tissue', 'Loss of mismatch repair protein expression; microsatellite instability', 'Diagnoses Lynch syndrome; guides immunotherapy (pembrolizumab for MSI-H/dMMR ovarian cancer)'],
      ['Multi-gene panel testing (NGS)', 'Blood', 'BRCA1/2, PALB2, BRIP1, RAD51C/D, ATM, CHEK2, Lynch genes (MLH1, MSH2, MSH6, PMS2)', 'Comprehensive hereditary assessment; identifies all moderate-high risk genes'],
    ],
    [2000, 1800, 3000, 2700]
  ),

  h2('PART 2: EFFECT OF GENETIC COUNSELLING ON MANAGEMENT OF OVARIAN CANCER'),

  h3('A. Effect on Treatment of the Affected Patient'),
  tbl(
    ['Finding', 'Management Impact'],
    [
      ['BRCA1/2 germline or somatic pathogenic mutation', 'PARP inhibitor (PARPi) maintenance therapy after first-line platinum-based chemotherapy. Olaparib (Lynparza) 300mg BD for 2 years \u2014 FDA/EMA/CDSCO approved for BRCA-mutated advanced EOC after CR/PR to platinum. Significantly improves PFS (SOLO-1 trial: median PFS not reached vs 13.8m for placebo; HR 0.30).'],
      ['HRD-positive tumour (even if BRCA wild-type)', 'Olaparib + bevacizumab (PAOLA-1 trial), or niraparib maintenance (PRIMA trial) offer PFS benefit in HRD-positive population.'],
      ['BRCAness (BRCA mutation or HRD)', 'Platinum sensitivity is enhanced \u2014 these tumours respond better to platinum-based chemotherapy due to impaired DNA repair'],
      ['BRCA mutation (relapsed setting)', 'PARPi therapy (olaparib, rucaparib, niraparib) as monotherapy for platinum-sensitive relapsed BRCA-mutated EOC \u2014 STUDY 19, SOLO-2, ARIEL3 trials'],
      ['Lynch syndrome / dMMR / MSI-H tumour', 'Pembrolizumab (anti-PD1 immunotherapy) approved for dMMR/MSI-H solid tumours including ovarian cancer (FDA 2017 tumour-agnostic approval). Dostarlimab + carboplatin/paclitaxel for dMMR endometrial cancer (GARNET trial) \u2014 being evaluated for ovarian.'],
      ['No actionable mutation found', 'Standard first-line treatment: debulking surgery + carboplatin/paclitaxel \u00b1 bevacizumab. Bevacizumab maintenance for HRD-negative tumours.'],
    ],
    [3000, 6500]
  ),

  h3('Key PARP Inhibitor Trials \u2014 Summary'),
  tbl(
    ['Trial', 'Drug', 'Population', 'Key Result'],
    [
      ['SOLO-1 (Moore et al., NEJM 2018)', 'Olaparib maintenance', 'BRCA1/2-mutated advanced EOC, CR/PR to 1st-line platinum', 'Median PFS: Not reached vs 13.8m (placebo); HR 0.30; 7-year OS benefit demonstrated (ESMO 2023)'],
      ['PAOLA-1 (Ray-Coquard et al., NEJM 2019)', 'Olaparib + bevacizumab', 'Advanced EOC, all-comers; subgroup: HRD positive', 'PFS benefit in HRD-positive population: 37.2m vs 17.7m (bevacizumab alone)'],
      ['PRIMA (Gonzalez-Martin et al., NEJM 2019)', 'Niraparib maintenance', 'Advanced EOC first-line; BRCA mutated and HRD positive', 'HRD-positive: PFS 21.9m vs 10.4m; BRCA-mutated: PFS 22.1m vs 10.9m'],
      ['SOLO-2 (Pujade-Lauraine et al., Lancet Oncol 2017)', 'Olaparib', 'BRCA-mutated platinum-sensitive relapsed EOC', 'PFS 19.1m vs 5.5m (chemotherapy); HR 0.30'],
      ['ARIEL3 (Coleman et al., Lancet 2017)', 'Rucaparib maintenance', 'Platinum-sensitive relapsed EOC; BRCA mutated/HRD positive', 'PFS benefit across all molecular subgroups; most pronounced in BRCA mutated'],
    ],
    [2500, 1500, 2500, 3000]
  ),

  h3('B. Effect on Surgical Management'),
  tbl(
    ['Genetic Finding', 'Surgical Management Consideration'],
    [
      ['BRCA1/2 mutation confirmed at time of EOC diagnosis', 'Discuss risk-reducing bilateral salpingo-oophorectomy (RRBSO) for contralateral adnexa if unilaternal disease. Standard complete surgical staging (BSO, omentectomy, PLND, peritoneal biopsies).'],
      ['BRCA1/2 mutation in relative of affected patient (cascade testing)', 'Risk-reducing bilateral salpingo-oophorectomy (RRBSO) recommended at: Age 35\u201340y for BRCA1 carriers (after childbearing complete); Age 40\u201345y for BRCA2 carriers. Reduces ovarian cancer risk by 80\u201390%; reduces breast cancer risk by 50% (pre-menopausal RRBSO).'],
      ['Lynch syndrome confirmed', 'Consider concurrent hysterectomy at time of EOC surgery (endometrial cancer risk 40\u201360% lifetime). Risk-reducing hysterectomy + BSO for Lynch carriers after childbearing.'],
    ],
    [3000, 6500]
  ),

  h3('C. Effect on Chemotherapy Selection'),
  bp('BRCA-mutated tumours show enhanced platinum sensitivity \u2014 higher response rates and longer duration of response to carboplatin/paclitaxel'),
  bp('Platinum rechallenge in BRCA-mutated relapsed disease is more likely to achieve response (platinum-free interval tends to be longer)'),
  bp('PARP inhibitors: exploit synthetic lethality \u2014 BRCA-mutated cells cannot repair double-strand DNA breaks by homologous recombination; PARPi blocks the only remaining repair pathway (base excision repair), causing cell death'),
  bp('Trabectedin (Yondelis): particularly active in BRCA-mutated EOC; approved in Europe for relapsed platinum-sensitive ovarian cancer'),

  h2('PART 3: GENETIC COUNSELLING FOR RISK REDUCTION IN UNAFFECTED CARRIERS'),

  h3('Risk-Reducing Strategies for BRCA1/2 Mutation Carriers (Unaffected Women)'),
  tbl(
    ['Strategy', 'Recommendation', 'Evidence / Guideline'],
    [
      ['Risk-Reducing Bilateral Salpingo-Oophorectomy (RRBSO)', 'BRCA1 carriers: age 35\u201340y (after childbearing). BRCA2 carriers: age 40\u201345y. Reduces ovarian cancer risk by ~80\u201390%; reduces breast cancer mortality by ~50% if pre-menopausal.', 'NCCN 2025, BGCS 2024, NICE NG61 2022, ESGO 2023: RRBSO is the single most effective risk-reduction intervention for BRCA carriers.'],
      ['Risk-Reducing Salpingectomy (RRS) with deferred oophorectomy', 'Option for women who want to preserve ovarian function temporarily; salpingectomy first; oophorectomy deferred to later age. Reduces risk of serous carcinoma arising in FT; does not give full ovarian cancer risk reduction.', 'Being studied in RRESDO and TUBA-WISP trials (UK). Not yet standard; offered in selected centres under trial.'],
      ['Enhanced surveillance (for those not ready for RRBSO)', 'Annual/biannual TVUS + CA-125 (every 6 months). NCCN: surveillance has limited sensitivity \u2014 NOT a substitute for RRBSO. Used as bridge to surgery for younger women.', 'NCCN 2025: surveillance is second-best option; RRBSO preferred once childbearing complete'],
      ['Oral contraceptive pill (OCP)', 'Use of OCP for \u22655 years reduces ovarian cancer risk in BRCA1 carriers by ~50%, BRCA2 by ~60% (case-control data). However, modest increase in breast cancer risk with OCP. Risk-benefit discussion individualised.', 'NCCN 2025: OCP may be considered for risk reduction in carriers who cannot/will not undergo RRBSO; not a substitute.'],
      ['HRT after RRBSO (surgical menopause)', 'Short-term HRT after RRBSO (until natural menopause age ~51) does NOT increase ovarian cancer risk (ovaries removed) and does NOT significantly increase breast cancer risk in BRCA1/2 carriers until age 51. Recommended for quality of life, bone, CV protection.', 'BGCS 2024, NCCN 2025: HRT after RRBSO is recommended for BRCA carriers until natural menopause age (51y).'],
    ],
    [2500, 4000, 3000]
  ),

  h3('Surveillance Recommendations for Lynch Syndrome (Ovarian/Gynaecological Cancer)'),
  tbl(
    ['Cancer Site', 'Recommendation (NCCN 2025 / HNPCC Guidelines)'],
    [
      ['Ovarian cancer surveillance', 'Annual TVUS + CA-125 from age 30\u201335y (limited sensitivity; RRBSO preferred after childbearing)'],
      ['Endometrial cancer surveillance', 'Annual endometrial biopsy from age 30\u201335y; OR risk-reducing hysterectomy + BSO after childbearing complete (reduces lifetime endometrial cancer risk by ~40\u201360%)'],
      ['Colorectal cancer surveillance', 'Colonoscopy every 1\u20132 years from age 25y'],
    ],
    [2500, 7000]
  ),

  h2('PART 4: PSYCHOLOGICAL AND ETHICAL ASPECTS OF GENETIC COUNSELLING'),
  tbl(
    ['Aspect', 'Management'],
    [
      ['Psychological impact of positive result', 'Anxiety, depression, survivor guilt (if family member affected), fear of cancer, relationship stress. Offer psychological support, cognitive behavioural therapy, peer support groups (e.g., FORCE \u2014 Facing Our Risk of Cancer Empowered). Follow-up appointments to address ongoing concerns.'],
      ['Impact on family members', 'Positive result implies 50% risk in first-degree relatives. Address concerns about disclosure to family. Facilitate cascade testing referrals. Family communication plan developed with patient.'],
      ['VUS (Variant of Uncertain Significance)', 'Currently cannot guide management. Monitor reclassification databases (ClinVar, LOVD, ENIGMA). DO NOT perform risk-reducing surgery based on VUS alone.'],
      ['Insurance and employment discrimination', 'In India: No specific legal protection for genetic discrimination. In UK/USA (GINA Act): legal protection against genetic discrimination in health insurance. Counsel patients about potential implications.'],
      ['Reproductive decisions', 'Carriers may opt for: PGT-M (Preimplantation Genetic Testing for Monogenic disorders) in IVF cycles to avoid transmitting BRCA mutation to offspring. Prenatal diagnosis (CVS/amniocentesis) is an option. Adoption. These are personal decisions requiring non-directive counselling.'],
      ['Adolescents and predictive testing', 'GENERALLY DEFERRED until adulthood (18y) unless medical management changes before 18y. Testing before 18y: only if actionable decisions arise (rare in BRCA syndrome). COPE/ESHG guidelines on paediatric genetic testing should be followed.'],
    ],
    [2800, 6700]
  ),

  h2('SUMMARY TABLE \u2014 GENETIC COUNSELLING IN OVARIAN CANCER'),
  tbl(
    ['Aspect', 'Key Point'],
    [
      ['Who to test', 'ALL women with EOC (universal testing \u2014 NCCN 2025, BGCS 2024)'],
      ['Most important genes', 'BRCA1 (39\u201344% lifetime OC risk), BRCA2 (11\u201318%), Lynch MMR genes, BRIP1, RAD51C/D'],
      ['Germline vs somatic testing', 'Both needed: germline (identifies family risk + PARPi eligibility), somatic/HRD (PARPi eligibility only)'],
      ['Treatment impact of BRCA mutation', 'PARPi maintenance (olaparib/niraparib/rucaparib) post-platinum \u2014 SOLO-1, PRIMA, PAOLA-1 trials'],
      ['Treatment impact of dMMR/MSI-H', 'Pembrolizumab (immunotherapy) \u2014 FDA tumour-agnostic approval'],
      ['Risk reduction for BRCA carriers', 'RRBSO: age 35\u201340y (BRCA1), 40\u201345y (BRCA2); reduces OC risk 80\u201390%'],
      ['Lynch syndrome management', 'Annual endometrial biopsy + TVUS; OR risk-reducing hysterectomy + BSO after childbearing'],
      ['Cascade testing', 'Offer to ALL first-degree relatives of mutation carriers'],
      ['Key guideline', 'BGCS 2024 (PMID 39002401) | NCCN Ovarian Cancer v2.2025 | ESGO/ESMO/ESTRO 2023 | NICE NG61 2022'],
    ],
    [2800, 6700]
  ),
  gBox('BGCS Ovarian Cancer Guidelines 2024 (Moss E et al., Eur J Obstet Gynecol 2024, PMID 39002401): All newly diagnosed EOC patients should be offered germline BRCA1/2 testing AND tumour BRCA/HRD testing. Universal genetic testing without family history criteria is now the recommended standard.'),
  divider()
);

// ===================================================
// QUESTION 10 — ENDOMETRIOSIS
// ===================================================
qHdr('10','10',
  '(a) Describe classification of endometriosis. [4 Marks]\n' +
  '(b) Discuss non-invasive diagnosis of endometriosis. [3 Marks]\n' +
  '(c) Treatment of a 32-year-old after definitive surgery for endometriosis. [3 Marks]'
).forEach(function(i){ C.push(i); });

C.push(
  h2('INTRODUCTION'),
  gBox('Based on: ESHRE Endometriosis Guideline 2022 (updated 2024) | ACOG Practice Bulletin No. 114 (Endometriosis) 2022 | ASRM Committee Opinion on Endometriosis 2022 | SOGC Clinical Practice Guideline on Endometriosis 2023 | World Endometriosis Society Consensus 2017 | rASRM Classification 1996 (still widely used) | ENZIAN Classification 2021'),

  p('Endometriosis is defined as the presence of endometrial-like epithelium and stroma outside the uterine cavity, typically in the pelvis. It affects 10% of women of reproductive age, 30\u201350% of women with infertility, and 70\u201380% of women with chronic pelvic pain. It is oestrogen-dependent and progesterone-resistant in its pathophysiology.'),

  h2('PART A: CLASSIFICATION OF ENDOMETRIOSIS'),
  h3('Overview of Classification Systems'),
  tbl(
    ['Classification System', 'Year', 'Type', 'Basis', 'Current Status'],
    [
      ['rASRM (Revised ASRM)', '1996', 'Surgical staging', 'Peritoneal implants, endometriomas, adhesions scored at laparoscopy; Stage I\u2013IV', 'Most widely used globally; poor correlation with pain/symptoms; moderate correlation with infertility'],
      ['ENZIAN Classification', '2021 (update)', 'Surgical staging \u2014 deep endometriosis', 'Specifically for deep infiltrating endometriosis (DIE); compartment-based', 'Preferred for DIE; better surgical planning'],
      ['EFI (Endometriosis Fertility Index)', '2010', 'Fertility prognosis', 'Predicts natural pregnancy after surgery; incorporates rASRM score + clinical factors', 'Best validated fertility prognosis tool'],
      ['ENZIAN/AAGL #Endometriosis Classification', '2021', 'Anatomical + surgical', 'Combines superficial peritoneal, ovarian, DIE, and associated features (#Endo)', 'Proposed to replace rASRM; more comprehensive'],
    ],
    [2500, 1000, 1800, 2500, 2200]
  ),

  h3('1. rASRM Classification (Revised American Society for Reproductive Medicine, 1996)'),
  p('Based on findings at laparoscopy. Points are assigned to: peritoneal implants (size, depth, location), endometriomas (size), adhesions (extent, type \u2014 filmy vs dense), and cul-de-sac obliteration. Total score determines stage:'),
  tbl(
    ['Stage', 'Name', 'Score', 'Description'],
    [
      ['Stage I', 'Minimal', '1\u20135', 'Isolated superficial implants, no significant adhesions. Lesions on peritoneum/ovary surface.'],
      ['Stage II', 'Mild', '6\u201315', 'Superficial and some deep implants; small endometrioma (<3cm); minor adhesions'],
      ['Stage III', 'Moderate', '16\u201340', 'Multiple superficial and deep implants; endometrioma \u22653cm; peritubal/periovarian adhesions; partial cul-de-sac obliteration'],
      ['Stage IV', 'Severe', '> 40', 'Multiple deep implants; large bilateral endometriomas; dense adhesions; complete cul-de-sac obliteration (frozen pelvis)'],
    ],
    [1000, 1500, 1200, 5800]
  ),
  noteBox('Limitation of rASRM: Stage does NOT correlate well with pain severity. Stage I disease can cause severe pain; Stage IV disease can be asymptomatic. However, higher rASRM stage correlates with lower spontaneous pregnancy rates after surgery.'),

  h3('2. ENZIAN Classification (2021) \u2014 For Deep Infiltrating Endometriosis (DIE)'),
  p('ENZIAN is specifically designed to characterise deep infiltrating endometriosis by compartment:'),
  tbl(
    ['Compartment', 'ENZIAN Code', 'Structures'],
    [
      ['Compartment A \u2014 Anterior', 'A1, A2, A3', 'Bladder (A1: bladder mucosa; A2: muscularis; A3: subvesical ureter), vesicovaginal space'],
      ['Compartment B \u2014 Lateral', 'B1, B2, B3 (right/left)', 'Uterosacral ligament (B1), parametrium (B2), ureter in parametrium (B3); always recorded right (r) and left (l) separately'],
      ['Compartment C \u2014 Posterior', 'C1, C2, C3', 'Vagina (C1), rectovaginal septum (C2), bowel wall (C3) \u2014 most common site for bowel endometriosis'],
      ['Additional features', 'F, O, T, I, X', 'F = fallopian tube; O = endometrioma; T = adenomyosis; I = other intestinal sites; X = other/distant sites'],
    ],
    [2200, 1800, 5500]
  ),
  noteBox('ENZIAN is the preferred classification for DIE as it guides surgical planning (multidisciplinary: bowel surgeon, urologist). It allows standardised pre-operative imaging interpretation and surgical team briefing.'),

  h3('3. EFI \u2014 Endometriosis Fertility Index'),
  p('Validated tool to predict chance of natural pregnancy after conservative surgery for endometriosis. Score 0\u201310 based on:'),
  tbl(
    ['Component', 'Sub-score'],
    [
      ['Least function score (LF score) \u2014 function of tubes + fimbriae + ovaries bilaterally assessed at surgery', '0\u20134 (bilateral assessment; worse side score used)'],
      ['AFS endometriosis lesion score (from rASRM)', 'Calculated from rASRM scoring'],
      ['AFS total score', 'From rASRM total'],
      ['Age', '<35y = 2 pts; 35\u201339y = 1 pt; \u226540y = 0 pts'],
      ['Duration of infertility', '<3y = 2 pts; \u22653y = 0 pts'],
      ['Prior pregnancy', 'Yes = 1 pt; No = 0 pts'],
    ],
    [5500, 4000]
  ),
  tbl(
    ['EFI Score', 'Expected Pregnancy Rate (3 years, natural conception)'],
    [
      ['9\u201310', '~75%'],
      ['7\u20138', '~56%'],
      ['5\u20136', '~30%'],
      ['3\u20134', '~22%'],
      ['0\u20132', '~10%'],
    ],
    [4000, 5500]
  ),
  gBox('ESHRE Endometriosis Guideline 2022: EFI should be calculated at time of surgical staging to counsel patients about natural conception chances post-surgery and decide timing of IVF referral.'),

  h2('PART B: NON-INVASIVE DIAGNOSIS OF ENDOMETRIOSIS'),
  gBox('ESHRE 2022 & ASRM 2022: Non-invasive diagnosis of endometriosis is the goal. The historical requirement for laparoscopic confirmation before treatment has been challenged. ESHRE 2022 recommends initiating empirical treatment based on symptoms and imaging in many cases, without mandatory surgical diagnosis.'),

  h3('A. Clinical Diagnosis \u2014 History and Examination'),
  tbl(
    ['Feature', 'Characteristic of Endometriosis'],
    [
      ['Classic symptom triad', 'Dysmenorrhoea (cyclic, worsening over years, often severe) + Chronic pelvic pain + Dyspareunia (deep, positional)'],
      ['Additional symptoms', 'Dyschezia (painful defecation \u2014 especially premenstrual), dysuria (premenstrual), haematuria (bladder endometriosis), rectal bleeding (bowel endometriosis), bloating, subfertility'],
      ['Cyclicity', 'Symptoms worse premenstrually and during menstruation; hallmark feature'],
      ['Clinical examination (TVCS)', 'Tender nodularity in posterior fornix/uterosacral ligaments; fixed retroversion; adnexal mass; tenderness on bimanual; speculum: blue/black lesions in posterior fornix (rare but pathognomonic)'],
      ['ESHRE 2022 recommendation', 'Endometriosis should be suspected and non-invasively assessed in women with: dysmenorrhoea + CPP + deep dyspareunia (any combination), particularly if symptoms affect quality of life'],
    ],
    [2500, 7000]
  ),

  h3('B. Imaging for Non-Invasive Diagnosis'),
  tbl(
    ['Modality', 'What it Detects', 'Sensitivity / Specificity', 'Recommendation'],
    [
      ['Transvaginal Ultrasound (TVUS) by trained sonographer', 'Endometriomas (ground-glass cyst with no flow on Doppler \u2014 \u201cchocolate cyst\u201d appearance); DIE of rectovaginal septum, bladder, uterosacral ligaments, bowel wall; adenomyosis features', 'Endometriomas: Sensitivity 93%, Specificity 96% (Cochrane). DIE overall: Sensitivity 79%, Specificity 94%', 'ESHRE 2022: TVUS is the FIRST-LINE imaging investigation. A normal TVUS does NOT exclude endometriosis (especially superficial peritoneal disease).'],
      ['Transvaginal Ultrasound specific signs', 'Sliding sign: negative sliding sign (no gliding of uterus/rectum against each other) indicates POD adhesion/obliteration; highly predictive of DIE. Probe tenderness at specific sites.', 'Negative sliding sign: Sensitivity 85%, Specificity 96% for POD obliteration', 'ESHRE 2022, ISUOG 2022: Sliding sign should be assessed in all women with suspected endometriosis on TVUS. Dynamic USS examination.'],
      ['MRI pelvis (with bowel prep)', 'Deep infiltrating endometriosis; bowel endometriosis (depth of invasion); bladder endometriosis; adenomyosis; endometriomas; frozen pelvis assessment; pre-surgical mapping', 'DIE: Sensitivity 94%, Specificity 77%. Superior to TVUS for posterior compartment DIE.', 'ESHRE 2022: MRI is recommended as second-line or adjunct to TVUS, especially for: deep infiltrating endometriosis pre-surgical planning; suspected bowel/bladder involvement; complex cases.'],
      ['Transrectal Ultrasound (TRUS)', 'Bowel endometriosis; rectovaginal DIE', 'Sensitivity 91%, Specificity 98% for bowel DIE', 'Alternative to TVUS for posterior compartment DIE; operator-dependent; less widely available'],
      ['Sonoelastography', 'Stiffness mapping of DIE lesions; distinguishes fibrotic DIE from normal tissue', 'Emerging; research tool', 'Not yet standard clinical tool'],
    ],
    [2500, 2500, 2200, 2300]
  ),
  noteBox('TVUS CANNOT reliably detect superficial peritoneal endometriosis (stage I/II rASRM). For these lesions, laparoscopy with biopsy remains the gold standard. However, ESHRE 2022 recommends that empirical medical treatment can be started without laparoscopic confirmation in women with characteristic symptoms, especially if they do not desire immediate fertility.'),

  h3('C. Biomarkers for Non-Invasive Diagnosis'),
  tbl(
    ['Biomarker', 'Status', 'Performance', 'Recommendation'],
    [
      ['CA-125 (serum)', 'Available; widely used', 'Poor sensitivity for stages I\u2013II (30\u201350%); better for stage III\u2013IV (sensitivity ~60\u201380%, specificity ~85%). Not specific for endometriosis (elevated in many conditions)', 'ESHRE 2022: CA-125 has limited diagnostic value for endometriosis. Should NOT be used as the sole diagnostic test. Useful for monitoring disease activity/recurrence post-treatment.'],
      ['CA-19-9 (serum)', 'Some data', 'Moderately elevated in deep endometriosis; poor specificity', 'Not recommended as standalone diagnostic test'],
      ['Endometrial secretome biomarkers (e.g., VEGF, IL-6, IL-8)', 'Research only', 'Promising but not clinically validated', 'Not recommended in routine practice (ESHRE 2022)'],
      ['miRNA-based signatures (urine/blood)', 'Research', 'High diagnostic accuracy in some studies; not clinically validated', 'Not recommended in routine practice'],
      ['Menstrual blood biomarkers', 'Research', 'Early data; non-invasive; promising', 'Not yet in clinical use'],
      ['NAPPA (Non-Invasive Proteomic Approach)', 'Research', 'Serum/urine protein panels being validated', 'Not yet clinical standard'],
    ],
    [2200, 1800, 2500, 3000]
  ),
  gBox('ESHRE Endometriosis Guideline 2022: No currently available biomarker or combination has sufficient sensitivity and specificity to replace laparoscopy for diagnosis of endometriosis. TVUS by a trained sonographer is the best non-invasive test. Empirical medical treatment is acceptable in women with characteristic symptoms and normal or non-diagnostic imaging.'),

  h3('D. Laparoscopy with Biopsy \u2014 Remains Gold Standard (when needed)'),
  bp('Direct visualisation of lesions + histological confirmation = definitive diagnosis'),
  bp('Required when: diagnosis unclear; treatment failure; suspicious malignancy; fertility workup requiring staging; prior to complex surgical planning'),
  bp('Typical appearances: powder-burn/gun-shot (black), red lesions (active), white/scarred lesions; endometriomas; adhesions; frozen pelvis'),
  bp('ESHRE 2022: Histological confirmation is strongly recommended when laparoscopy is performed. Multiple biopsies from different lesions to confirm diagnosis.'),

  h2('PART C: TREATMENT OF A 32-YEAR-OLD AFTER DEFINITIVE SURGERY FOR ENDOMETRIOSIS'),
  p('A 32-year-old woman who has undergone "definitive surgery" for endometriosis implies she has had either: (a) bilateral salpingo-oophorectomy (BSO) +/- hysterectomy (radical/definitive surgery), OR (b) the question may refer to definitive excision of all visible endometriosis lesions at laparoscopy (conservative-definitive surgery). Given the age of 32, both scenarios require careful post-operative management. We will address both interpretations.'),

  h3('Scenario 1: Definitive Surgery = Bilateral Salpingo-Oophorectomy (BSO) +/- Hysterectomy at Age 32'),
  p('BSO at age 32 induces surgical menopause. Without HRT, this woman faces serious long-term health consequences:'),
  tbl(
    ['Consequence of Untreated Surgical Menopause at 32y', 'Risk'],
    [
      ['Osteoporosis', 'Accelerated bone loss begins immediately post-BSO; fracture risk doubles without HRT'],
      ['Cardiovascular disease', '2\u20133\u00d7 increased CVD risk vs natural menopause; early atherosclerosis'],
      ['Urogenital atrophy (GSM)', 'Vaginal dryness, dyspareunia, recurrent UTI; major quality of life impact'],
      ['Cognitive effects', 'Higher risk of cognitive decline and dementia with early surgical menopause without HRT'],
      ['Sexual dysfunction', 'Testosterone deficiency + GSM + psychological impact of surgical menopause'],
      ['Vasomotor symptoms', 'Severe hot flushes, night sweats, sleep disturbance; surgical menopause is more abrupt and severe than natural menopause'],
    ],
    [3500, 6000]
  ),

  h3('Post-Operative Medical Management After BSO + Hysterectomy for Endometriosis (Age 32)'),
  tbl(
    ['Treatment', 'Recommendation (ESHRE 2022 / RCOG / BMS 2024)'],
    [
      ['Hormone Replacement Therapy (HRT) \u2014 MANDATORY', 'Start HRT IMMEDIATELY post-operatively. Continue until natural menopause age (51y). No uterus \u2192 estrogen-only therapy is safe and preferred. Transdermal estrogen preferred (gel/patch) for CV and thrombotic safety.'],
      ['Estrogen type and dose', 'Transdermal 17\u03b2-estradiol: 100mcg patch or 2\u20134 pumps gel/day OR oral estradiol valerate 2mg/day (transdermal preferred for VTE safety). Higher doses may be needed for symptom control in young surgical menopause.'],
      ['Progestogen (if uterus removed)', 'NOT required for endometrial protection (no uterus). Progestogen-only HRT has no benefit post-hysterectomy.'],
      ['SPECIAL CONSIDERATION: Endometriosis residual risk', 'If residual endometriosis tissue remains \u2014 rare risk of estrogen-stimulated recurrence. Adding tibolone OR cyclic progestogen to estrogen may be considered. ESHRE 2022: For most women post-hysterectomy+BSO for endometriosis, estrogen-only HRT is safe and does NOT stimulate recurrence significantly; benefits outweigh risks.'],
      ['Testosterone supplementation', 'Consider transdermal testosterone (off-label) for low libido / hypoactive sexual desire disorder (HSDD) post-surgical menopause (BMS 2024 guideline: consider testosterone after estrogen optimised)'],
      ['Bone health', 'DEXA scan at baseline (surgical menopause is major osteoporosis risk factor). Calcium 1000\u20131200mg/day + Vitamin D 800\u20131000IU/day. HRT is primary bone protection. Bisphosphonates only if HRT contraindicated.'],
      ['Cardiovascular protection', 'HRT (especially transdermal) is cardioprotective until age 51. Annual BP; lipid profile every 2\u20133 years; promote exercise, healthy weight, smoking cessation.'],
      ['Psychological support', 'Surgical menopause at 32 is a major life event. Counselling for: loss of fertility, menopausal symptoms, sexual health, body image, relationship impact. Refer to menopause specialist/psychologist if needed.'],
      ['Sexual health', 'Local vaginal estrogen (safe even on systemic HRT) for GSM. Vaginal moisturisers + lubricants. Psychosexual counselling if dyspareunia persists.'],
      ['Duration of HRT', 'Continue until age 51 (natural menopause age). Review annually. Do NOT stop prematurely.'],
      ['Annual follow-up', 'BP, weight, BMD (DEXA every 2\u20135y), lipids, symptoms assessment, psychological wellbeing, sexual health review'],
    ],
    [2500, 7000]
  ),

  h3('Scenario 2: Definitive Surgery = Complete Laparoscopic Excision of All Visible Endometriosis (Conservative-Definitive Surgery, Uterus + Ovaries Preserved)'),

  h3('Post-Operative Medical Suppression to Prevent Recurrence'),
  tbl(
    ['Treatment', 'Recommendation (ESHRE 2022)'],
    [
      ['Goal of post-operative medical therapy', 'Prevent/delay recurrence of endometriosis after surgical excision. Recurrence rate without post-operative treatment: ~21\u201340% at 5 years.'],
      ['Combined Oral Contraceptive Pill (COCP)', 'First-line: cyclic or continuous low-dose OCP (e.g., norethisterone + EE, or desogestrel + EE). Continuous pill preferred \u2014 suppresses ovulation and reduces menstrual flow. ESHRE 2022 Level A recommendation for recurrence prevention.'],
      ['Progestogen-only therapy', 'Norethisterone acetate (NETA) 5mg OD, or dienogest 2mg OD (MOST EVIDENCE \u2014 Visanne). Dienogest: superior to other progestogens for pain relief and recurrence prevention. Levonorgestrel IUS (Mirena) also effective for pain + recurrence prevention.'],
      ['Dienogest (Visanne) 2mg OD \u2014 FIRST-LINE progestogen', 'Superior to placebo and comparable to GnRH agonists for pain relief. Safe for long-term use (no hypoestrogenic side effects of GnRH-a). ESHRE 2022: Dienogest is a first-line medical treatment for endometriosis-associated pain.'],
      ['GnRH agonists (Leuprolide, Goserelin, Buserelin)', 'Highly effective but cause hypoestrogenism (menopausal symptoms, bone loss). Limit to 6 months without add-back HRT. ESHRE 2022: GnRH-a with add-back therapy (low-dose estrogen + progestogen) can be used long-term. NOT first-line post-surgery when OCP/progestogen equally effective.'],
      ['GnRH antagonists (Elagolix, Linzagolix, Relugolix)', 'Newer agents; oral; rapidly reversible. Elagolix (Orilissa) approved FDA 2018 for endometriosis-associated pain. ESHRE 2022: emerging evidence; may replace GnRH-a for long-term medical management.'],
      ['Levonorgestrel IUS (Mirena)', 'Effective for pain + recurrence prevention. Reduces menstrual blood loss. Duration 5 years. ESHRE 2022: IUS is an effective option for endometriosis-associated pain in women not desiring immediate pregnancy.'],
      ['Duration of post-operative medical treatment', 'Minimum 18\u201324 months (ESHRE 2022 recommendation). Continue long-term until pregnancy desired or menopause. Do NOT stop when symptoms resolve \u2014 silent recurrence continues.'],
    ],
    [2500, 7000]
  ),

  h3('Fertility Considerations at Age 32 After Conservative Endometriosis Surgery'),
  tbl(
    ['Scenario', 'Recommendation'],
    [
      ['Wants pregnancy now/soon', 'Do NOT use hormonal suppression. Calculate EFI score. If EFI high (\u22657): attempt natural conception for 6\u201312 months. If EFI low (<7) or age >35y at next review: refer for IVF/ICSI without delay.'],
      ['Not ready for pregnancy now', 'Use long-term hormonal suppression (OCP or dienogest) to prevent recurrence. Counsel that ovarian reserve may decline with recurrence; time-sensitive decision.'],
      ['Endometriomas surgically removed', 'Counsel that: bilateral endometrioma cystectomy reduces ovarian reserve (AMH falls post-surgery); IVF success may be lower if recurrence; balance risk of repeat surgery vs medical management.'],
      ['IVF timing after surgery', 'ESHRE 2022: Consider IVF sooner if: bilateral endometriomas, poor ovarian reserve (AMH low), age >35y, long duration infertility, failed natural conception post-surgery, or EFI <7.'],
    ],
    [2800, 6700]
  ),

  h2('POST-OPERATIVE MANAGEMENT SUMMARY TABLE \u2014 FOR EXAM'),
  tbl(
    ['Situation', 'Goal', 'First-Line Treatment (ESHRE 2022)'],
    [
      ['After BSO (+/- hysterectomy) at age 32 \u2014 no uterus', 'Manage surgical menopause; prevent osteoporosis/CVD; quality of life', 'IMMEDIATE estrogen-only HRT (transdermal preferred); continue until age 51; calcium + Vit D; psychological support; sexual health'],
      ['After conservative excision of endometriosis, no pregnancy desired', 'Prevent recurrence; pain control', 'OCP (continuous) OR dienogest 2mg OD; minimum 18\u201324 months. LNG-IUS is alternative.'],
      ['After conservative excision, pregnancy desired now', 'Optimise fertility; no hormonal suppression', 'Calculate EFI; attempt natural conception; refer IVF if EFI <7 or no conception after 12 months'],
      ['After conservative excision, no pregnancy desired \u2014 pain persists', 'Sustained pain control + recurrence prevention', 'Dienogest 2mg OD; if inadequate: GnRH agonist with add-back HRT; consider repeat surgery if imaging shows recurrence'],
    ],
    [3000, 2500, 4000]
  ),
  gBox('Key Guidelines: ESHRE Endometriosis Guideline 2022 (updated 2024) | ACOG Practice Bulletin No. 114 2022 | ASRM Committee Opinion 2022 | SOGC CPG on Endometriosis 2023 | BMS Position Statement on Surgical Menopause 2024'),

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  h2('REFERENCES AND GUIDELINES CITED'),
  tbl(
    ['Question', 'Guideline / Reference'],
    [
      ['Q9', 'BGCS Ovarian Cancer Guidelines 2024 (PMID 39002401) | NCCN Ovarian Cancer v2.2025 | ASCO BRCA Testing Guideline 2020 | ESGO/ESMO/ESTRO Ovarian Cancer Guidelines 2023 | NICE NG61 2022 | SGO Genetic Testing Statement 2024 | SOLO-1 (NEJM 2018) | PAOLA-1 (NEJM 2019) | PRIMA (NEJM 2019) | SOLO-2 (Lancet Oncol 2017) | ARIEL3 (Lancet 2017)'],
      ['Q10', 'ESHRE Endometriosis Guideline 2022/2024 | ACOG Practice Bulletin 114 2022 | ASRM Committee Opinion on Endometriosis 2022 | SOGC CPG 2023 | rASRM Classification 1996 | ENZIAN Classification 2021 | EFI (Adamson & Pasta, Fertil Steril 2010) | BMS Surgical Menopause Position Statement 2024'],
    ],
    [800, 8700]
  )
);

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    properties: { page: { margin: { top: 1000, bottom: 1000, left: 1100, right: 1100 } } },
    headers: { default: new Header({ children: [new Paragraph({ children: [new TextRun({ text: 'DNB OBG Dec 2022 | Paper 4 Answer Bank (Q9\u2013Q10)  |  Evidence-Based | PG Mentor Format', size: 17, color: '1F3864', font: 'Calibri' })], alignment: AlignmentType.RIGHT, border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: '2E74B5' } } })] }) },
    footers: { default: new Footer({ children: [new Paragraph({ children: [new TextRun({ text: 'For educational/academic use only | Latest guidelines 2025   \u2014   Page ', size: 17, font: 'Calibri' }), new TextRun({ children: [PageNumber.CURRENT], size: 17, font: 'Calibri' }), new TextRun({ text: ' of ', size: 17, font: 'Calibri' }), new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 17, font: 'Calibri' })], alignment: AlignmentType.CENTER, border: { top: { style: BorderStyle.SINGLE, size: 6, color: '2E74B5' } } })] }) },
    children: C,
  }],
});

Packer.toBuffer(doc).then(function(buf) {
  fs.writeFileSync('/home/daytona/workspace/DNB-OBG-Dec22-P4/DNB_OBG_Dec22_P4_AnswerBank_Q9to10.docx', buf);
  console.log('SUCCESS');
}).catch(function(e){ console.error('ERROR:', e.message); process.exit(1); });

cd /home/daytona/workspace/DNB-OBG-Dec22-P4 && node generate_q9q10.js 2>&1

python3 -c " import zipfile, os p = '/home/daytona/workspace/DNB-OBG-Dec22-P4/DN…