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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 1 — Title
titleSlide(
  "Small for Gestational Age (SGA)\nvs\nFetal Growth Restriction (FGR)",
  "A Comprehensive Clinical Overview | Obstetrics & Gynaecology"
);

// ─── SLIDE 2 — Overview / Agenda ────────────────────────────────────────────
contentSlide("Overview: What We Will Cover", [
  "1.  Definitions — SGA & FGR",
  "2.  Historical perspective & terminology evolution",
  "3.  Normal fetal growth physiology",
  "4.  Classification of FGR (Symmetric vs Asymmetric; Early vs Late)",
  "5.  Etiology — Maternal, Fetal, Placental, Environmental",
  "6.  Risk factors & screening",
  "7.  Diagnosis — Ultrasound biometry & customized growth curves",
  "8.  Doppler ultrasound surveillance",
  "9.  Biophysical profile & other surveillance tools",
  "10. Management — Remote from term vs near term",
  "11. Timing of delivery",
  "12. Perinatal outcomes & long-term complications",
  "13. Key differences: SGA vs FGR",
  "14. Summary & take-home points",
]);

// ─── SLIDE 3 — Definitions ──────────────────────────────────────────────────
contentSlide("Definitions: SGA & FGR", [
  "Small for Gestational Age (SGA): Birth weight < 10th percentile for gestational age on population-based growth curves",
  "Fetal Growth Restriction (FGR): A fetus that does NOT achieve its growth potential — the biologically optimal weight for that individual fetus",
  "Key distinction: Not all SGA infants are growth-restricted; some are constitutionally small but healthy",
  "Conversely, adverse perinatal outcome may be increased even in fetuses with weights between the 10th–90th percentile who have not achieved growth potential",
  "FGR is NOT a homogeneous entity — different phenotypes behave differently (e.g., FGR in preeclampsia vs idiopathic FGR)",
  "No universally accepted international definition exists for FGR; definition varies by region and institution",
]);

// ─── SLIDE 4 — Historical Perspective ──────────────────────────────────────
contentSlide("Historical Perspective & Terminology Evolution", [
  "Early 20th century: ALL small newborns were classified as 'premature'",
  "Mid 20th century: Concept of the 'undernourished neonate' arose",
  "WHO definition: Newborns weighing < 2500 g classified as 'low-birth-weight (LBW) infants'",
  "1960s: Lubchenco et al. published landmark graphs of birth weight vs gestational age (the first growth curves)",
  "Three categories defined: SGA (< 10th %ile), AGA (10th–90th %ile), LGA (> 90th %ile)",
  "Lubchenco curves: Limitations — do NOT reflect modern birth weight changes, ethnic variability, or altitude differences",
  "Modern approach (1998–2006, n > 391,000): New sex-specific, ethnically diverse US growth standards developed",
  "Trend now: Move from population-based SGA toward customized FGR diagnosis",
]);

// ─── SLIDE 5 — Normal Fetal Growth ──────────────────────────────────────────
contentSlide("Normal Fetal Growth: Three Phases", [
  "PHASE 1 — Cellular Hyperplasia (first half of pregnancy): Growth driven by rapid cell division; small absolute weight gain",
  "PHASE 2 — Hyperplasia + Hypertrophy (mid-pregnancy): Both cell number and cell size increase; weight gain accelerates",
  "PHASE 3 — Hypertrophic Growth (last 6–8 weeks): Cell enlargement dominates; maximum absolute weight gain",
  "Growth rate: 5 g/day at 14–15 wks  →  10 g/day at 20 wks  →  30–35 g/day at 32–34 wks",
  "Peak weekly gain: 230–285 g at 32–34 weeks, then declines — may reach zero at 41–42 weeks",
  "If expressed as % increase per week: Maximum in 1st trimester, decreases steadily thereafter",
  "Placental weight increases throughout normal gestation; in FGR, plateaus after 36 wks; trimmed placenta < 350 g",
]);

// ─── SLIDE 6 — Classification: Symmetric vs Asymmetric ─────────────────────
contentSlide("Classification of FGR", [],
  {
    twoCol: true,
    colAHead: "SYMMETRIC FGR (~20-30%)",
    colBHead: "ASYMMETRIC FGR (~70-80%)",
    colA: [
      "Proportionate reduction in ALL measurements: weight, length, head circumference",
      "Caused by factors acting early in pregnancy (hyperplastic phase)",
      "Common causes: Aneuploidy (e.g., trisomies), structural malformations, fetal infections (TORCH), teratogens",
      "Smaller but 'normally proportioned' fetus",
      "Long-standing placental disorders may also cause symmetric pattern",
      "Generally worse prognosis when associated with genetic/structural anomalies",
    ],
    colB: [
      "Normal skeletal dimensions & head circumference BUT reduced abdominal circumference and subcutaneous tissue",
      "Brain-sparing effect: Blood preferentially directed to brain, adrenals, heart",
      "Caused by placental dysfunction — aberrant implantation, inadequate placental tissue, placental destruction",
      "Typically manifests in late 2nd or 3rd trimester",
      "Asymmetric pattern may evolve into symmetric appearance if prolonged",
      "Better prognosis if underlying cause (placental) is treated/managed",
    ],
  }
);

// ─── SLIDE 7 — Early vs Late FGR ────────────────────────────────────────────
contentSlide("Early vs Late FGR: Two Clinical Phenotypes", [], {
  twoCol: true,
  colAHead: "EARLY FGR (< 32 weeks)",
  colBHead: "LATE FGR (≥ 32 weeks)",
  colA: [
    "Less common (~20–30% of FGR cases)",
    "More severe placental dysfunction",
    "Strong association with preeclampsia and other hypertensive disorders",
    "More pronounced Doppler abnormalities (absent/reversed EDF in UA)",
    "Higher perinatal mortality and morbidity",
    "Management: Expectant with intensive surveillance; balance prematurity vs fetal compromise",
    "BOX 44.1: Periviable < 25 wks; Very early 25–28 wks; Early > 28 to < 32 wks",
  ],
  colB: [
    "More common (~70–80% of FGR cases)",
    "Milder placental dysfunction",
    "Less commonly associated with preeclampsia",
    "Subtle Doppler changes: MCA PI reduction (cerebral redistribution), mildly elevated UA PI",
    "Absent/reversed EDF is rare in late FGR",
    "Higher risk of stillbirth due to delayed diagnosis",
    "Management: Delivery planning near term; often induced at 37–40 weeks",
  ],
});

// ─── SLIDE 8 — Etiology: Maternal Factors ───────────────────────────────────
contentSlide("Etiology of FGR: Maternal Factors", [
  "VASCULAR / HYPERTENSIVE: Chronic hypertension, preeclampsia, renal disease — impaired uteroplacental perfusion",
  "CARDIORESPIRATORY: Cyanotic congenital heart disease, severe asthma, high-altitude residence — reduced O2 delivery",
  "HEMATOLOGICAL: Antiphospholipid syndrome, thrombophilias, sickle cell disease — placental thrombosis/infarction",
  "METABOLIC: Poorly controlled diabetes mellitus (paradox: usually LGA but severe vascular disease → SGA)",
  "NUTRITIONAL: Severe malnutrition, very low pre-pregnancy BMI; inadequate gestational weight gain",
  "IMMUNOLOGICAL: Autoimmune diseases (SLE, RA), collagen vascular disorders",
  "UTERINE ANOMALIES: Uterine fibroids, bicornuate uterus — reduced uterine capacity",
  "PREVIOUS OBSTETRIC HISTORY: Previous FGR, stillbirth, preterm delivery — recurrence risk 25–50%",
]);

// ─── SLIDE 9 — Etiology: Fetal & Placental Factors ──────────────────────────
contentSlide("Etiology of FGR: Fetal, Placental & Environmental Factors", [], {
  twoCol: true,
  colAHead: "FETAL FACTORS",
  colBHead: "PLACENTAL + ENVIRONMENTAL FACTORS",
  colA: [
    "Chromosomal anomalies: Trisomy 13, 18, 21; Triploidy; Turner syndrome (45X)",
    "Structural malformations: Cardiac defects, gastroschisis, renal agenesis",
    "Congenital infections: CMV, Rubella, Toxoplasma, Syphilis, Varicella (TORCH)",
    "Multiple gestation: Twin-to-twin transfusion syndrome (TTTS), growth discordance > 18%",
    "Metabolic disorders: Inborn errors of metabolism",
    "Single umbilical artery (controversy in absence of aneuploidy)",
  ],
  colB: [
    "Placental insufficiency: Shallow trophoblast invasion → failure of spiral artery remodeling",
    "Chromosomally normal FGR: Placenta 24% smaller for gestational age",
    "Abnormal cord insertions: Velamentous insertion (SGA in 17% vs 10.2% controls)",
    "Placental hemangiomas, abruption, previa",
    "Smoking: -135 to -300 g birth weight; dose-response relationship for head circumference reduction",
    "Alcohol: Even 1–2 drinks/day reduces birth weight",
    "Cocaine: Reduces birth weight + head circumference",
    "Drugs: Carbamazepine, phenytoin, atenolol, heroin, antineoplastics",
  ],
});

// ─── SLIDE 10 — Placental Pathophysiology ───────────────────────────────────
contentSlide("Placental Pathophysiology of FGR", [
  "Normal: Cytotrophoblasts invade decidua and remodel uterine spiral arteries → low-resistance, high-flow uteroplacental circulation",
  "In FGR (especially early FGR): Shallow cytotrophoblast invasion → spiral arteries retain muscular walls → high resistance, low flow",
  "Consequence 1: Reduced umbilical blood flow per kg fetal weight → elevated umbilical artery pulsatility index (PI)",
  "Consequence 2: Decreased vasosyncytial membranes → greater fraction of O2 diffuses across thick oxygen-consuming barrier → LOW placental O2 permeability",
  "Consequence 3: Reduced transplacental glucose diffusion → fetal hypoglycemia and growth slowing",
  "Fetal O2 compensation: Low PO2 enlarges the transplacental PO2 gradient (draws more O2 in) AND reduces fetal growth demand",
  "Advanced disease: UA absent end-diastolic velocity → reversed EDF → fetal acidemia, multi-organ dysfunction",
  "Placental weight < 350 g (trimmed) is a pathological finding in FGR",
]);

// ─── SLIDE 11 — Screening & Risk Stratification ─────────────────────────────
contentSlide("Screening, Risk Factors & Prevention", [
  "FIRST-TRIMESTER SCREENING: Low PAPP-A, elevated free beta-hCG, low inhibin A → higher risk of FGR",
  "UTERINE ARTERY DOPPLER (11–13 wks): Bilateral notching + elevated PI → impaired trophoblast invasion; pooled sensitivity ~40%, specificity ~93% for early-onset FGR",
  "CUSTOMIZED GROWTH CURVES: Adjust for maternal race, height, weight, parity → identify true FGR among SGA; reduces false positives",
  "HIGH-RISK GROUPS: Previous FGR (recurrence 25–50%), preeclampsia, APS, renal disease, heavy smokers, multiple gestation",
  "LOW-DOSE ASPIRIN (75–150 mg/day from < 16 wks): Reduces risk of FGR by 20% in high-risk women (Cochrane meta-analysis); also reduces preeclampsia",
  "SMOKING CESSATION before 3rd trimester: Reduces adverse effect on birth weight",
  "UTERINE ARTERY PI > 95th %ile at 20–24 wks: Strong predictor for subsequent placental FGR",
]);

// ─── SLIDE 12 — Diagnosis: Ultrasound ───────────────────────────────────────
contentSlide("Diagnosis: Ultrasound Biometry & Growth Assessment", [
  "PRIMARY TOOL: Ultrasound estimation of fetal weight (EFW) using Hadlock formula — HC, AC, BPD, FL",
  "SGA diagnosis: EFW or AC < 10th percentile on population-based or customized growth curves",
  "ABDOMINAL CIRCUMFERENCE (AC): Most sensitive single biometric parameter for detecting FGR; reduces as liver glycogen is depleted",
  "GROWTH VELOCITY: Serial ultrasound every 2–4 weeks; a plateau or decline in growth velocity is more significant than a single low EFW",
  "AMNIOTIC FLUID VOLUME (AFV): Oligohydramnios (AFI < 5 cm or MVP < 2 cm) indicates severe FGR; reflects fetal renal hypoperfusion",
  "Constitutionally small fetus: Normal growth velocity + normal Doppler + normal AFV + no maternal risk factors",
  "First critical clinical challenge: Distinguishing a constitutionally small normal fetus from a true FGR fetus",
  "PORTO study: Small fetuses with NORMAL UA Doppler — adverse outcome only 1.3% vs 11.5% with abnormal Doppler",
]);

// ─── SLIDE 13 — Doppler Surveillance ────────────────────────────────────────
contentSlide("Doppler Ultrasound Surveillance in FGR", [
  "UMBILICAL ARTERY (UA) DOPPLER: PRIMARY surveillance tool in FGR; reflects placental vascular resistance",
  "  - Normal end-diastolic velocity: Usually indicates constitutionally small, well-compensated fetus",
  "  - Elevated PI (> 95th %ile): Increased placental resistance; step up surveillance",
  "  - Absent end-diastolic velocity (AEDV): Associated with terminal villous maldevelopment; significant neonatal morbidity",
  "  - Reversed end-diastolic velocity (REDV): Extreme placental resistance; high risk of fetal acidemia, mortality",
  "MIDDLE CEREBRAL ARTERY (MCA) DOPPLER: Reduced PI = cerebral vasodilation = 'brain-sparing'; useful in late FGR",
  "CEREBROPLACENTAL RATIO (CPR = MCA PI / UA PI): Ratio < 1.0 indicates redistribution; adverse outcome predictor in late FGR",
  "DUCTUS VENOSUS (DV): Absent or reversed a-wave = venous hypertension, pre-terminal; SMFM does not recommend routine use",
  "Cochrane review (19 RCTs): UA Doppler use → fewer perinatal deaths (RR 0.71), fewer IOL (RR 0.89), fewer CS (RR 0.90)",
]);

// ─── SLIDE 14 — Biophysical Profile & CTG ───────────────────────────────────
contentSlide("Fetal Surveillance: BPP, NST & Cardiotocography", [
  "BIOPHYSICAL PROFILE (BPP): Assesses 5 parameters (NST, fetal breathing movements, fetal tone, gross body movement, AFV) — each scored 0 or 2",
  "  Score 8–10: Reassuring; Score 6: Equivocal (repeat in 24 hrs or deliver if term); Score 0–4: Deliver",
  "NON-STRESS TEST (NST): Baseline variability and reactivity; loss of variability is an ominous late sign in FGR",
  "CARDIOTOCOGRAPHY (CTG): Used in conjunction with Doppler and BPP; computerized CTG (cCTG) preferred for objective short-term variability",
  "INTEGRATED SURVEILLANCE PROTOCOL (Creasy & Resnik recommendation):",
  "  - Serial ultrasound biometry (every 2–4 wks) + UA Doppler + AFV assessment",
  "  - Abnormal UA Doppler → add MCA, DV assessment, and twice-weekly CTG/BPP",
  "  - Surveillance frequency determined by severity of growth restriction",
  "PORTO STUDY conclusion: Integrated monitoring with ultrasound biometry, Doppler and CTG optimizes timing of delivery",
]);

// ─── SLIDE 15 — Management: Remote from Term ────────────────────────────────
contentSlide("Management: Remote from Term (< 34 Weeks)", [
  "Goals: Maximize fetal maturity while avoiding fetal compromise; balance prematurity vs in-utero deterioration",
  "INPATIENT vs OUTPATIENT: Individualized based on severity; AEDV/REDV warrant hospitalization",
  "ANTENATAL CORTICOSTEROIDS: Betamethasone 12 mg IM × 2 doses (24 hrs apart) if delivery anticipated at 24–34 weeks — accelerates lung maturity",
  "MAGNESIUM SULFATE: Neuroprotection if delivery < 32 weeks — reduces risk of cerebral palsy",
  "MATERNAL BED REST: Not proven to improve outcomes; may reduce oxygen consumption marginally",
  "AVOID/TREAT: Underlying maternal conditions (hypertension, infections, drugs); optimize nutrition",
  "SURVEILLANCE ESCALATION based on UA Doppler:",
  "  Normal UA: Biometry q 2–4 wks, AFV weekly",
  "  Elevated PI: Biometry q 2 wks, UA + AFV twice weekly",
  "  AEDV: Hospitalize; daily/twice daily CTG + BPP; consider delivery at 34 wks",
  "  REDV: Deliver after corticosteroids if ≥ 26 wks; individualize at periviable gestation",
]);

// ─── SLIDE 16 — Management: Timing of Delivery ──────────────────────────────
contentSlide("Timing of Delivery in FGR", [], {
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    ],
    [
      { text: "Near-term FGR (≥ 37 wks) with any Doppler abnormality", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Deliver at 37–38 weeks", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Risk of stillbirth outweighs benefit of further maturity", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
    ],
  ],
  colW: [3.2, 2.4, 3.9],
});

// ─── SLIDE 17 — Perinatal Outcomes ──────────────────────────────────────────
contentSlide("Perinatal Outcomes & Neonatal Complications", [], {
  twoCol: true,
  colAHead: "IMMEDIATE COMPLICATIONS",
  colBHead: "LONG-TERM / ADULT CONSEQUENCES",
  colA: [
    "Perinatal asphyxia & acidemia",
    "Meconium aspiration syndrome",
    "Hypoglycemia (depleted glycogen stores)",
    "Hypothermia (reduced subcutaneous fat)",
    "Polycythemia / hyperviscosity (chronic hypoxia → erythropoiesis)",
    "Necrotizing enterocolitis (NEC)",
    "Intraventricular hemorrhage (IVH) in preterm FGR",
    "Increased risk of NICU admission and prolonged stay",
    "Perinatal mortality: 4–8× higher than AGA infants",
  ],
  colB: [
    "Barker Hypothesis (Developmental Origins of Health and Disease - DOHaD):",
    "FGR programs metabolic adaptations that persist into adult life",
    "Hypertension in adult life (RR ~1.5–2x)",
    "Type 2 diabetes mellitus (insulin resistance)",
    "Coronary artery disease & atherosclerosis",
    "Stroke and cerebrovascular disease",
    "Metabolic syndrome",
    "Neurodevelopmental delay, lower IQ, behavioral issues (especially in early FGR)",
    "Impaired immune function",
  ],
});

// ─── SLIDE 18 — SGA vs FGR: Side-by-Side Comparison ────────────────────────
contentSlide("SGA vs FGR: Key Differences at a Glance", [], {
  tableData: [
    [
      { text: "Feature", options: { bold: true, color: DARK_BG, fill: ACCENT, fontSize: 11, fontFace: "Calibri" } },
      { text: "SGA", options: { bold: true, color: DARK_BG, fill: ACCENT, fontSize: 11, fontFace: "Calibri" } },
      { text: "FGR", options: { bold: true, color: DARK_BG, fill: ACCENT, fontSize: 11, fontFace: "Calibri" } },
    ],
    [
      { text: "Definition", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Birth weight < 10th percentile (population-based)", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Failure to achieve biological growth potential", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Basis", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Statistical / normative (population reference)", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Pathophysiological / individualized", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Pathology present?", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Not necessarily; may be constitutionally small", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Yes — underlying pathological process", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Doppler", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Usually normal UA Doppler", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Abnormal UA Doppler (elevated PI, AEDV, REDV)", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Growth velocity", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Normal — parallel to centiles", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Decreasing / plateauing — crossing centiles downward", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Amniotic fluid", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Normal AFV", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Oligohydramnios (in moderate–severe FGR)", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
    ],
    [
      { text: "Outcome risk", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "Low if constitutionally small (PORTO: 1.3% adverse outcome)", options: { color: WHITE, fill: MID_BG, fontSize: 10, fontFace: "Calibri" } },
      { text: "High (PORTO: 11.5% adverse outcome with abnormal Doppler)", options: { color: YELLOW, fill: MID_BG, fontSize: 10, fontFace: "Calibri", bold: true } },
    ],
    [
      { text: "Management approach", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Expectant; deliver at or near term", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
      { text: "Intensive surveillance; individualized delivery timing", options: { color: WHITE, fill: GRAY_CARD, fontSize: 10, fontFace: "Calibri" } },
    ],
  ],
  colW: [2.4, 3.55, 3.55],
});

// ─── SLIDE 19 — Patterns of Deterioration ───────────────────────────────────
contentSlide("Progression & Patterns of Deterioration in FGR", [
  "FGR follows a predictable sequence of hemodynamic deterioration (especially early FGR):",
  "STEP 1 — Placental insufficiency develops: UA PI rises (increased resistance); normal MCA and DV",
  "STEP 2 — Fetal redistribution: MCA PI falls (cerebral vasodilation / 'brain sparing'); CPR < 1.0",
  "STEP 3 — Severe placental disease: UA absent end-diastolic velocity (AEDV); oligohydramnios develops",
  "STEP 4 — Venous compromise: DV a-wave diminished → absent → reversed; hepatic venous pulsations appear",
  "STEP 5 — Terminal deterioration: Reversed UA EDF; CTG shows late decelerations, reduced variability; BPP < 4",
  "Late FGR often shows only MCA/CPR changes without UA AEDV — pattern is more subtle",
  "Clinical implication: Delivery must occur before Step 4/5; earlier intervention = better neonatal outcome",
  "PORTO study confirmed: Integrated biometry + Doppler + CTG is gold standard for monitoring progression",
]);

// ─── SLIDE 20 — Summary & Take-Home Points ──────────────────────────────────
contentSlide("Summary & Take-Home Points", [
  "SGA (< 10th %ile by population curves) is NOT synonymous with FGR; many SGA infants are constitutionally small and healthy",
  "FGR = failure to achieve growth potential; requires individualized assessment using customized growth curves and Doppler",
  "Two main types of FGR: Symmetric (early insult, often genetic/infectious) vs Asymmetric (late, placental)",
  "Early FGR (< 32 wks) is more severe; Late FGR (≥ 32 wks) is more common and subtler — risk of missed diagnosis",
  "UA Doppler is the PRIMARY surveillance tool; absent/reversed EDF is an obstetric emergency",
  "MCA Doppler + CPR ratio is key for detecting brain-sparing — especially important in late FGR",
  "Optimal outcomes require integrated monitoring: biometry + Doppler + AFV + CTG/BPP",
  "Betamethasone for lung maturation if delivery expected at 24–34 wks; MgSO4 for neuroprotection < 32 wks",
  "Long-term: FGR programs adult cardiovascular, metabolic, and neurodevelopmental disease (Barker/DOHaD hypothesis)",
  "Early screening: Low PAPP-A + uterine artery Doppler → low-dose aspirin from < 16 wks reduces FGR risk by 20%",
]);

// ─── Write file ─────────────────────────────────────────────────────────────
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