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pres.title = "Pathological Diseases in Pregnancy";
pres.author = "MD Medicine";

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// ─── OUTLINE ────────────────────────────────────────────────
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  const sections = [
    { num:"01", title:"Liver Diseases of Pregnancy", color:C.teal },
    { num:"02", title:"Thyroid Disorders in Pregnancy", color:C.gold },
    { num:"03", title:"Heart Disease in Pregnancy", color:C.red },
  ];
  const subtopics = [
    ["Physiologic changes  |  ICP  |  HELLP  |  AFLP  |  HG  |  Preeclampsia  |  Chronic liver disease"],
    ["Physiologic changes  |  Hypothyroidism  |  Hyperthyroidism  |  Graves' disease  |  Postpartum thyroiditis"],
    ["Hemodynamic changes  |  Valvular disease  |  Congenital HD  |  Peripartum CMP  |  Pulmonary HTN  |  Management"],
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// ══════════════════════════════════════════════════════════════
// SECTION 1 — LIVER DISEASE IN PREGNANCY
// ══════════════════════════════════════════════════════════════
sectionDivider(pres, "01", "LIVER DISEASE\nIN PREGNANCY", "Classification · Diagnosis · Management", C.teal);

// S1-1: Physiologic changes
contentSlide(pres, "Liver Physiology During Pregnancy", C.teal, [
  { text:"NORMAL PHYSIOLOGIC CHANGES", isHeading:true },
  { text:"Plasma volume increases ~50%; hepatic blood flow unchanged (lower % of cardiac output)" },
  { text:"Estrogen rises → spider telangiectasias, palmar erythema (normal findings)" },
  { text:"Physical exam limited — gravid uterus displaces liver into chest; palpable liver in late pregnancy = ABNORMAL" },
  { text:"Up to 3% of pregnancies complicated by abnormal liver chemistries" },
  { text:"" },
  { text:"BIOCHEMICAL CHANGES IN NORMAL PREGNANCY", isHeading:true },
  { text:"Decreased: Albumin (hemodilution), GGT, Conjugated bilirubin, Total bilirubin" },
  { text:"Increased: Alkaline phosphatase (placental + bone isoenzyme — NOT a reliable marker in 3rd trimester)" },
  { text:"Increased: Fibrinogen, Factors V, VII, VIII, α-fetoprotein (fetal liver), 5'-nucleotidase" },
  { text:"Unchanged: ALT, AST (normal reference ranges apply)" },
  { text:"" },
  { text:"CLASSIFICATION OF LIVER DISEASE IN PREGNANCY", isHeading:true },
  { text:"Category 1: Unique to pregnancy (ICP, AFLP, HELLP, HG)" },
  { text:"Category 2: Occurring more commonly due to pregnancy (viral hepatitis E, gallstones)" },
  { text:"Category 3: Underlying / pre-existing liver disease (autoimmune hepatitis, cirrhosis, PBC)" },
]);

// S1-2: Intrahepatic Cholestasis
contentSlide(pres, "Intrahepatic Cholestasis of Pregnancy (ICP)", C.teal, {
  left: [
    { text:"EPIDEMIOLOGY & RISK FACTORS", isHeading:true },
    { text:"Most common pregnancy-specific liver disease" },
    { text:"Incidence: 0.2–2% (higher in South America, Scandinavia)" },
    { text:"Usually 3rd trimester; rarely 2nd trimester" },
    { text:"Risk factors: Multiple gestation, prior ICP, family Hx" },
    { text:"" },
    { text:"PATHOPHYSIOLOGY", isHeading:true },
    { text:"Impaired bile acid transport (ABCB4/ABCB11 gene mutations)" },
    { text:"Estrogen/progesterone inhibit bile secretion" },
    { text:"Elevated serum total bile acids (>10 μmol/L)" },
    { text:"Severe ICP: bile acids >40 μmol/L → fetal risk ↑↑" },
    { text:"" },
    { text:"CLINICAL FEATURES", isHeading:true },
    { text:"Pruritus (hallmark) — palms & soles, nocturnal ↑" },
    { text:"No primary rash; excoriation marks" },
    { text:"Mild jaundice in 10–25%" },
    { text:"Steatorrhea, vitamin K deficiency in severe cases" },
  ],
  right: [
    { text:"INVESTIGATIONS", isHeading:true },
    { text:"↑ Serum bile acids (fasting; >10 μmol/L diagnostic)" },
    { text:"↑ ALT/AST (2–10× ULN)" },
    { text:"Alkaline phosphatase: unreliable (placental component)" },
    { text:"Bilirubin: mildly elevated in 25%" },
    { text:"Clotting: PT may be prolonged (fat-malabsorption)" },
    { text:"" },
    { text:"MATERNAL RISKS", isHeading:true },
    { text:"Pruritus, insomnia, steatorrhea" },
    { text:"Postpartum hemorrhage (vitamin K deficiency)" },
    { text:"Recurrence in 45–70% of subsequent pregnancies" },
    { text:"" },
    { text:"FETAL RISKS", isHeading:true },
    { text:"Preterm birth, meconium-stained liquor" },
    { text:"Intrauterine fetal death (bile acids >40 μmol/L)" },
    { text:"" },
    { text:"MANAGEMENT", isHeading:true },
    { text:"Ursodeoxycholic acid (UDCA) — 1st line; reduces pruritus & bile acids" },
    { text:"Cholestyramine — 2nd line; add vitamin K supplementation" },
    { text:"Deliver at 37–38 weeks in severe ICP" },
    { text:"Fetal surveillance: NST, biophysical profile weekly" },
  ]
}, true);

// S1-3: HELLP
contentSlide(pres, "HELLP Syndrome", C.teal, {
  left: [
    { text:"DEFINITION & CLASSIFICATION", isHeading:true },
    { text:"Hemolysis, Elevated Liver enzymes, Low Platelets" },
    { text:"Severe variant of preeclampsia (found in 0.5–0.9% of all pregnancies, 10–20% of severe preeclampsia)" },
    { text:"Tennessee Classification (Martin):" },
    { text:"  Class I: Platelets <50,000/μL", indent:1 },
    { text:"  Class II: Platelets 50,000–100,000/μL", indent:1 },
    { text:"  Class III: Platelets 100,000–150,000/μL", indent:1 },
    { text:"Mississippi Triple-Class: adds LDH + AST thresholds" },
    { text:"" },
    { text:"PATHOPHYSIOLOGY", isHeading:true },
    { text:"Abnormal placentation → endothelial dysfunction" },
    { text:"Microangiopathic hemolytic anemia" },
    { text:"Platelet aggregation & consumption" },
    { text:"Periportal hepatic necrosis → fibrin deposition" },
  ],
  right: [
    { text:"DIAGNOSTIC CRITERIA", isHeading:true },
    { text:"Hemolysis: abnormal blood smear, LDH >600 U/L, total bilirubin >1.2 mg/dL" },
    { text:"Elevated Liver Enzymes: AST >70 U/L" },
    { text:"Low Platelets: <100,000/μL" },
    { text:"" },
    { text:"CLINICAL FEATURES", isHeading:true },
    { text:"Epigastric / RUQ pain (90%), nausea/vomiting" },
    { text:"Malaise, headache, visual changes" },
    { text:"Hypertension & proteinuria (not universal)" },
    { text:"Most cases present 28–36 weeks; 30% postpartum" },
    { text:"" },
    { text:"COMPLICATIONS", isHeading:true },
    { text:"Liver hematoma/rupture (rare but life-threatening)" },
    { text:"Placental abruption, DIC, acute renal failure" },
    { text:"Pulmonary edema" },
    { text:"" },
    { text:"MANAGEMENT", isHeading:true },
    { text:"Immediate stabilization (MgSO₄, antihypertensives)" },
    { text:"Corticosteroids (betamethasone / dexamethasone) — accelerate platelet recovery" },
    { text:"Definitive treatment: DELIVERY (regardless of gestational age if ≥34 wks)" },
    { text:"Recurrence risk 2–27% in subsequent pregnancies" },
  ]
}, true);

// S1-4: AFLP
contentSlide(pres, "Acute Fatty Liver of Pregnancy (AFLP)", C.teal, {
  left: [
    { text:"OVERVIEW", isHeading:true },
    { text:"Rare but life-threatening: microvesicular fatty infiltration → acute hepatic failure" },
    { text:"Incidence: 5/100,000 pregnancies (UK national cohort)" },
    { text:"Typically 3rd trimester (median 36 weeks)" },
    { text:"Twin pregnancies & low BMI (<20) are risk factors" },
    { text:"" },
    { text:"PATHOGENESIS", isHeading:true },
    { text:"Associated with fetal LCHAD deficiency (Long-chain 3-hydroxyacyl-CoA dehydrogenase)" },
    { text:"Homozygous LCHAD-deficient fetus → unmetabolized long-chain fatty acids spill into maternal circulation" },
    { text:"Mother often heterozygous for LCHAD mutation" },
    { text:"Accumulation of fatty acid metabolites → hepatotoxicity" },
    { text:"" },
    { text:"SWANSEA CRITERIA (≥6 of following):", isHeading:true },
    { text:"Vomiting, Abdominal pain, Polydipsia/polyuria" },
    { text:"Encephalopathy, Elevated bilirubin >0.8 mg/dL" },
    { text:"Hypoglycemia <72 mg/dL, Elevated uric acid >340 μmol/L" },
    { text:"Leukocytosis >11×10⁹/L, Elevated AST/ALT >42 IU/L" },
    { text:"Renal impairment, Coagulopathy (PT >14 s)" },
    { text:"Microvesicular steatosis on liver biopsy" },
  ],
  right: [
    { text:"CLINICAL PRESENTATION", isHeading:true },
    { text:"Prodrome: 1–2 weeks nausea, vomiting, abdominal pain" },
    { text:"Progressive jaundice, encephalopathy" },
    { text:"Hypoglycemia (↓ hepatic gluconeogenesis)" },
    { text:"Coagulopathy (DIC-like), renal failure" },
    { text:"Concomitant preeclampsia in ~50%" },
    { text:"Central diabetes insipidus (rare but described)" },
    { text:"" },
    { text:"INVESTIGATIONS", isHeading:true },
    { text:"↑ ALT/AST (markedly elevated), ↑ bilirubin" },
    { text:"↓ Glucose, ↓ Fibrinogen, ↑ PT/INR" },
    { text:"↑ WBC, ↑ uric acid, ↑ creatinine" },
    { text:"Ultrasound: echogenic liver (non-specific)" },
    { text:"Liver biopsy: microvesicular steatosis (rarely needed)" },
    { text:"" },
    { text:"MANAGEMENT", isHeading:true },
    { text:"ICU admission — aggressive supportive care" },
    { text:"Correct hypoglycemia (IV dextrose), coagulopathy (FFP, platelets)" },
    { text:"IMMEDIATE DELIVERY is the only cure" },
    { text:"Cesarean section preferred given coagulopathy risk" },
    { text:"Liver transplantation: if no recovery post-delivery" },
    { text:"Neonatal screening for LCHAD deficiency" },
    { text:"Prognosis: excellent with early recognition (mortality <1% maternal in current era)" },
  ]
}, true);

// S1-5: Chronic liver disease / AIH / PBC
contentSlide(pres, "Chronic Liver Disease in Pregnancy", C.teal, [
  { text:"AUTOIMMUNE HEPATITIS (AIH)", isHeading:true },
  { text:"Most common chronic nonviral hepatitis in reproductive-age women" },
  { text:"AIH Type 1: ANA+, SMA+ | AIH Type 2: anti-LKM1+, anti-LKM3+, anti-LC1+" },
  { text:"Classic phenotype: amenorrhea & infertility → improve with immunosuppression" },
  { text:"Postpartum flare risk: 33% (especially if no therapy or pre-conception flare)" },
  { text:"Treatment: prednisolone + azathioprine (safe in pregnancy; continue to prevent flare)" },
  { text:"Outcomes: live birth rate 73%; preterm birth 20%; maternal complication rate 38%" },
  { text:"" },
  { text:"PRIMARY BILIARY CIRRHOSIS (PBC)", isHeading:true },
  { text:"Autoimmune, antimitochondrial antibody (AMA) positive" },
  { text:"Rare in pregnancy; usually well-controlled disease can achieve successful pregnancy" },
  { text:"UDCA continues to be used; pruritus can worsen in pregnancy" },
  { text:"" },
  { text:"VIRAL HEPATITIS IN PREGNANCY", isHeading:true },
  { text:"Hepatitis B: vertical transmission 70–90% if HBeAg+; TDF (Tenofovir) for prophylaxis in high viral load" },
  { text:"Hepatitis E: disproportionately severe in pregnancy — 20–25% mortality; fulminant hepatic failure risk" },
  { text:"Hepatitis C: transmission risk ~5%; peginterferon + ribavirin contraindicated; defer to post-delivery" },
  { text:"" },
  { text:"CIRRHOSIS IN PREGNANCY", isHeading:true },
  { text:"Severe portal hypertension: risk of variceal bleeding ↑↑ (especially 2nd trimester — increased blood volume)" },
  { text:"Endoscopy recommended 2nd trimester; non-selective beta blockers & TIPS in selected cases" },
  { text:"Obstetric outcomes worse: preterm birth, IUGR, maternal morbidity & mortality increased" },
]);

// ══════════════════════════════════════════════════════════════
// SECTION 2 — THYROID DISORDERS IN PREGNANCY
// ══════════════════════════════════════════════════════════════
sectionDivider(pres, "02", "THYROID DISORDERS\nIN PREGNANCY", "Hypothyroidism · Hyperthyroidism · Screening · Postpartum Thyroiditis", C.gold);

// S2-1: Physiology
contentSlide(pres, "Thyroid Physiology in Pregnancy", C.gold, [
  { text:"EPIDEMIOLOGY", isHeading:true },
  { text:"~4% of pregnant women have a history of thyroid disease, develop it during pregnancy, or are first diagnosed within 5 years postpartum" },
  { text:"" },
  { text:"PHYSIOLOGIC CHANGES TO THE THYROID AXIS", isHeading:true },
  { text:"TBG (thyroid-binding globulin): Estrogen ↑ hepatic synthesis + ↓ metabolism → 1.5× increase by 6–8 weeks gestation; remains elevated throughout" },
  { text:"Total T3 & T4: INCREASE (due to ↑ TBG) — do NOT reflect free hormone levels" },
  { text:"hCG effect: shares α subunit with TSH → acts as TSH agonist on thyroid in 1st trimester" },
  { text:"  → Physiologic rise in T4/T3 → feedback suppression of TSH in 1st trimester", indent:1 },
  { text:"  → TSH lower limit decreases by ~0.4 mU/L; upper limit decreases by ~0.5 mU/L (ATA 2017)", indent:1 },
  { text:"Free T4: transient rise in 1st trimester (high hCG) → gradual fall in 2nd and 3rd trimesters" },
  { text:"TSH pattern: low in 1st trimester → rises in 2nd and 3rd trimester as hCG falls" },
  { text:"" },
  { text:"TRIMESTER-SPECIFIC TSH REFERENCE RANGES (ATA 2017)", isHeading:true },
  { text:"Use population- and trimester-specific reference intervals for TSH (laboratory-specific)" },
  { text:"If not available: lower limit −0.4 mU/L; upper limit −0.5 mU/L vs nonpregnant reference" },
  { text:"First trimester: ~0.1–2.5 mU/L | Second trimester: ~0.2–3.0 mU/L | Third trimester: ~0.3–3.0 mU/L" },
  { text:"" },
  { text:"NOTE: Liquid chromatography-tandem mass spectrometry is more reliable than immunoassay for fT3/fT4 in pregnancy (high TBG + low albumin affect immunoassay)" },
]);

// S2-2: Hypothyroidism
contentSlide(pres, "Hypothyroidism in Pregnancy", C.gold, {
  left: [
    { text:"PREVALENCE & ETIOLOGY", isHeading:true },
    { text:"Overt hypothyroidism: ~0.5% of pregnant women" },
    { text:"Subclinical hypothyroidism (SCH): 2–3% (most common)" },
    { text:"Most common cause worldwide: iodine deficiency" },
    { text:"Developed countries: Hashimoto's thyroiditis (TPOAb+)" },
    { text:"10–20% of women in childbearing years have TPO or Tg autoantibodies" },
    { text:"" },
    { text:"DIAGNOSIS", isHeading:true },
    { text:"↑ TSH (above trimester-specific upper limit) + ↓ fT4" },
    { text:"Overt: ↑ TSH + ↓ fT4 (symptomatic)" },
    { text:"SCH: ↑ TSH with normal fT4" },
    { text:"Isolated hypothyroxinemia: ↓ fT4 with normal TSH (significance unclear)" },
    { text:"" },
    { text:"CLINICAL FEATURES", isHeading:true },
    { text:"Fatigue, weight gain, cold intolerance, constipation" },
    { text:"Bradycardia, dry skin, hair loss, myxedema" },
    { text:"Symptoms often overlap with normal pregnancy — diagnosis may be missed" },
  ],
  right: [
    { text:"MATERNAL & FETAL RISKS (Untreated)", isHeading:true },
    { text:"Maternal: miscarriage, preeclampsia, preterm delivery, placental abruption" },
    { text:"Fetal: neonatal mortality (preterm), IUGR, decreased IQ / cognitive impairment" },
    { text:"TPOAb+ euthyroid women: ↑ miscarriage, preterm delivery, postpartum thyroiditis" },
    { text:"" },
    { text:"TREATMENT (ATA 2017 Recommendations)", isHeading:true },
    { text:"Levothyroxine (L-T4) for all pregnant women with:" },
    { text:"  TSH > trimester-specific upper limit + ↓ fT4", indent:1 },
    { text:"  TSH > 10 mU/L regardless of fT4", indent:1 },
    { text:"  TSH > upper limit + TPOAb positive", indent:1 },
    { text:"Target TSH: <2.5 mU/L in 1st trimester; <3.0 mU/L in 2nd/3rd" },
    { text:"Dose increase: ~25–50% in first trimester (anticipatory in known hypothyroid women)" },
    { text:"Monitor TSH every 4 weeks until 20 weeks, then at 24–28 weeks, 32–34 weeks" },
    { text:"Postpartum: return to prepregnancy dose; recheck TSH at 6 weeks postpartum" },
    { text:"" },
    { text:"TPOAb-POSITIVE EUTHYROID WOMEN", isHeading:true },
    { text:"LT4 reduces miscarriage risk (1 RCT), but NOT currently recommended by major societies" },
  ]
}, true);

// S2-3: Hyperthyroidism / Graves
contentSlide(pres, "Hyperthyroidism in Pregnancy", C.gold, {
  left: [
    { text:"ETIOLOGY", isHeading:true },
    { text:"Graves' disease: most common cause (85%); autoimmune TRAb stimulation" },
    { text:"Gestational transient thyrotoxicosis (GTT): 2nd most common; hCG-driven" },
    { text:"Other: toxic multinodular goiter, toxic adenoma, subacute thyroiditis" },
    { text:"hCG-induced: multiple gestation, gestational trophoblastic disease (hydatidiform mole, choriocarcinoma)" },
    { text:"" },
    { text:"GESTATIONAL TRANSIENT THYROTOXICOSIS (GTT)", isHeading:true },
    { text:"Biochemical: ↓ TSH + ↑ fT4 in 1st trimester (peak hCG)" },
    { text:"Associated with hyperemesis gravidarum" },
    { text:"No antithyroid drugs needed; supportive care (rehydration, antiemetics)" },
    { text:"Key: EXCLUDE Graves' disease (TRAb, goiter, ophthalmopathy → Graves')" },
    { text:"" },
    { text:"GRAVES' DISEASE — CLINICAL FEATURES", isHeading:true },
    { text:"Palpitations, tremor, heat intolerance, weight loss" },
    { text:"Goiter, proptosis/exophthalmos (Graves' specific)" },
    { text:"Pretibial myxedema, thyroid bruit" },
    { text:"TRAb (thyroid receptor antibodies) positive" },
  ],
  right: [
    { text:"FETAL & NEONATAL RISKS", isHeading:true },
    { text:"Neonatal hyperthyroidism: TRAb crosses placenta → stimulates fetal thyroid" },
    { text:"Neonatal hypothyroidism: excess ATD crosses placenta" },
    { text:"IUGR, preterm birth, fetal loss if uncontrolled" },
    { text:"Monitor TRAb at 22–26 weeks gestation" },
    { text:"" },
    { text:"ANTITHYROID DRUG THERAPY", isHeading:true },
    { text:"1st Trimester: Propylthiouracil (PTU) PREFERRED" },
    { text:"  (Methimazole associated with aplasia cutis, choanal atresia, tracheoesophageal fistula)", indent:1 },
    { text:"After 1st trimester: Switch to Methimazole (MMI)" },
    { text:"  (PTU — risk of hepatotoxicity with prolonged use)", indent:1 },
    { text:"Target: maintain fT4 in upper-normal range on lowest effective ATD dose" },
    { text:"Monitor TFTs every 2–4 weeks; aim for euthyroid state" },
    { text:"" },
    { text:"ADDITIONAL MANAGEMENT", isHeading:true },
    { text:"Propranolol: for symptom control (limited duration; risks: IUGR, neonatal bradycardia)" },
    { text:"Radioiodine: CONTRAINDICATED in pregnancy (fetal thyroid ablation)" },
    { text:"Surgery (thyroidectomy): 2nd trimester if required; rarely needed" },
    { text:"Postpartum: Graves' often flares; adjust dosing accordingly" },
  ]
}, true);

// S2-4: Postpartum Thyroiditis
contentSlide(pres, "Postpartum Thyroiditis & Thyroid Screening", C.gold, [
  { text:"POSTPARTUM THYROIDITIS", isHeading:true },
  { text:"Incidence: 4–9% of unselected postpartum women (geographic variation)" },
  { text:"Autoimmune destructive thyroiditis — distinct from Graves' disease" },
  { text:"" },
  { text:"BIPHASIC PATTERN:", isHeading:true },
  { text:"Phase 1 — Thyrotoxic phase (2–6 months postpartum): follicular destruction releases stored thyroid hormone → ↓ TSH, ↑ T4" },
  { text:"Phase 2 — Hypothyroid phase (4–8 months postpartum): gland depleted → ↑ TSH, ↓ T4; may become permanent in 20–40%" },
  { text:"" },
  { text:"DISTINGUISHING POSTPARTUM THYROIDITIS vs GRAVES' DISEASE", isHeading:true },
  { text:"Graves: goiter + ophthalmopathy + TRAb+ + HIGH radioiodine/technetium uptake" },
  { text:"PPT: NO goiter/ophthalmopathy, TRAb negative, LOW uptake (destructive)" },
  { text:"" },
  { text:"TREATMENT", isHeading:true },
  { text:"Thyrotoxic phase: beta-blockers only (propranolol) if symptomatic; no ATDs (not synthesis-dependent)" },
  { text:"Hypothyroid phase: levothyroxine if symptomatic or TSH >10; especially if planning further pregnancy" },
  { text:"Recurrence: common in subsequent pregnancies" },
  { text:"" },
  { text:"THYROID SCREENING IN PREGNANCY", isHeading:true },
  { text:"Universal vs targeted screening: debated (ATA supports case-finding; ACOG, Endocrine Society favor targeted)" },
  { text:"Targeted screening indications: prior thyroid disease, TPOAb+, symptoms, infertility, prior miscarriage, family history, obesity, goiter, Type 1 DM, autoimmune disease, neck irradiation, iodine deficiency region" },
  { text:"Screen with TSH at first prenatal visit in high-risk women" },
]);

// ══════════════════════════════════════════════════════════════
// SECTION 3 — HEART DISEASE IN PREGNANCY
// ══════════════════════════════════════════════════════════════
sectionDivider(pres, "03", "HEART DISEASE\nIN PREGNANCY", "Hemodynamics · Valvular · Congenital · Peripartum CMP · Management", C.red);

// S3-1: Hemodynamic changes
contentSlide(pres, "Cardiovascular Physiology in Pregnancy", C.red, [
  { text:"EPIDEMIOLOGY", isHeading:true },
  { text:"Cardiac disease = LEADING indirect cause of maternal death (USA & UK)" },
  { text:"Prevalence: 1–4% of pregnancies; rising due to increasing maternal age, obesity, CHD survivors reaching reproductive age" },
  { text:"" },
  { text:"NORMAL HEMODYNAMIC CHANGES IN PREGNANCY", isHeading:true },
  { text:"Plasma volume: ↑ 40–50% (starts week 6, peaks week 28–32)" },
  { text:"Red cell mass: ↑ 20–30% → dilutional anemia (physiologic)" },
  { text:"Cardiac output: ↑ 30–50% (↑ heart rate + ↑ stroke volume)" },
  { text:"Heart rate: ↑ 10–20 bpm from baseline" },
  { text:"Systemic vascular resistance: ↓ (progesterone-mediated vasodilatation)" },
  { text:"Blood pressure: slightly ↓ in 1st/2nd trimester, returns to baseline in 3rd" },
  { text:"Critical period: CO peaks at 28–30 weeks; further ↑ at delivery (+500 mL auto-transfusion on contraction)" },
  { text:"" },
  { text:"SYMPTOMS MIMICKING CARDIAC DISEASE (Normal Pregnancy)", isHeading:true },
  { text:"Dyspnea, palpitations, fatigue, peripheral edema, systolic flow murmur — common in normal pregnancy" },
  { text:"RED FLAGS requiring further evaluation: loud systolic murmur (grade ≥3), any diastolic murmur, persistent symptoms, cyanosis, clubbing, syncope" },
  { text:"" },
  { text:"RISK STRATIFICATION: NYHA CLASS", isHeading:true },
  { text:"NYHA I: No symptoms at any activity — low risk, standard care" },
  { text:"NYHA II: Symptoms with moderate exertion — manageable, cardiology input required" },
  { text:"NYHA III: Symptoms with minimal activity — HIGH RISK; antenatal optimization + delivery planning" },
  { text:"NYHA IV: Symptoms at rest — VERY HIGH RISK; ICU care, consider termination of pregnancy" },
]);

// S3-2: WHO Classification table
tableSlide(pres, "WHO Classification of Cardiovascular Risk in Pregnancy", C.red,
  ["WHO Class", "Condition", "Risk", "Management"],
  [
    ["I", "Uncomplicated small VSD/ASD/PDA; corrected simple lesions; isolated ectopics", "No detectable risk", "Normal antenatal care"],
    ["II", "Uncorrected ASD/VSD; repaired ToF; most arrhythmias; mild LV impairment", "Small ↑ risk", "Cardiology review each trimester"],
    ["II-III", "Mild mitral/aortic stenosis; HCM; Marfan without aortic dilation; AVSD repaired", "Moderate ↑ risk", "Expert centre; frequent monitoring"],
    ["III", "Mechanical valve; Fontan circulation; moderate LV dysfunction; moderate MS; aortic root 40–45 mm (Marfan)", "Significantly ↑ risk; expert care required", "Tertiary cardiac centre; monthly review"],
    ["IV (contraindicated)", "PAH; severe systemic ventricular dysfunction (EF<30%); severe MS; aortic root >45 mm (Marfan/BiAV >50 mm)", "Extremely high risk of maternal death or severe morbidity", "Pregnancy strongly contraindicated; if pregnant, termination discussed"]
  ]
);

// S3-3: Valvular disease
contentSlide(pres, "Valvular Heart Disease in Pregnancy", C.red, {
  left: [
    { text:"GENERAL PRINCIPLE", isHeading:true },
    { text:"Stenotic lesions: POORLY tolerated (fixed obstruction + ↑ CO demands)" },
    { text:"Regurgitant lesions: BETTER tolerated (↓ SVR helps forward flow)" },
    { text:"" },
    { text:"MITRAL STENOSIS", isHeading:true },
    { text:"Most common RHD in pregnancy (worldwide); high risk" },
    { text:"↑ HR → ↓ diastolic filling time → ↑ LA pressure → pulmonary edema" },
    { text:"Complications: pulmonary edema, AF, thromboembolism" },
    { text:"Management: beta-blockers (rate control), diuretics, anticoagulation" },
    { text:"If severe (MVA <1.5 cm²): percutaneous mitral commissurotomy in 2nd trimester preferred over surgery" },
    { text:"" },
    { text:"AORTIC STENOSIS", isHeading:true },
    { text:"Severe AS (AVA <1.0 cm²): high maternal mortality" },
    { text:"Fixed obstruction → cannot accommodate ↑ CO demands" },
    { text:"Balloon valvuloplasty: option in extreme cases; high-risk" },
    { text:"Delivery: often hemodynamically complex; epidural may ↓ SVR dangerously" },
  ],
  right: [
    { text:"MITRAL REGURGITATION", isHeading:true },
    { text:"Generally well tolerated (↓ SVR → ↓ regurgitant fraction)" },
    { text:"Monitor for AF, acute decompensation" },
    { text:"Vasodilators (hydralazine, nifedipine) if symptomatic" },
    { text:"" },
    { text:"AORTIC REGURGITATION", isHeading:true },
    { text:"Well tolerated in pregnancy; ↑ HR + ↓ SVR ↓ regurgitant volume" },
    { text:"Severe AR with LV dysfunction: high risk; vasodilators" },
    { text:"" },
    { text:"MECHANICAL HEART VALVES", isHeading:true },
    { text:"HIGHEST RISK valvular condition in pregnancy" },
    { text:"Hypercoagulable state: ↑ thrombosis risk → require therapeutic anticoagulation throughout" },
    { text:"Anticoagulation dilemma:" },
    { text:"  Warfarin: most effective but teratogenic (6–9 weeks — embryopathy)", indent:1 },
    { text:"  LMWH: safe for fetus but ↑ valve thrombosis risk", indent:1 },
    { text:"  Unfractionated heparin: IV for peripartum", indent:1 },
    { text:"Strategy: LMWH or UFH in 1st trimester, warfarin in 2nd/3rd trimester, switch to IV UFH at 36 weeks" },
    { text:"" },
    { text:"ENDOCARDITIS PROPHYLAXIS", isHeading:true },
    { text:"NOT recommended for vaginal/C-section in absence of infection" },
    { text:"Exception: prosthetic valves, prior IE, unrepaired cyanotic CHD" },
  ]
}, true);

// S3-4: Congenital Heart Disease
contentSlide(pres, "Congenital Heart Disease & Peripartum Cardiomyopathy", C.red, {
  left: [
    { text:"CONGENITAL HEART DISEASE (CHD)", isHeading:true },
    { text:"Growing burden: advances in pediatric cardiology → more women reaching childbearing age" },
    { text:"Consult adult CHD-specialist cardiologist — physiology post-repair is complex" },
    { text:"" },
    { text:"HIGH-RISK CHD LESIONS", isHeading:true },
    { text:"Eisenmenger syndrome / pulmonary arterial hypertension: maternal mortality 30–50% — pregnancy contraindicated" },
    { text:"Cyanotic CHD (unrepaired): ↑ IUGR, miscarriage; cyanosis → polycythemia → thrombosis" },
    { text:"Right-to-left shunts: air bubbles in IV lines → paradoxical embolism — strict IV care" },
    { text:"Fontan circulation: ↑ preload-dependent; poor tolerance of vasodilatation" },
    { text:"Marfan syndrome: aortic root >40 mm → significant risk of dissection" },
    { text:"  Aortic root >45 mm: delivery before pregnancy / contraindication", indent:1 },
    { text:"" },
    { text:"LOWER-RISK CHD", isHeading:true },
    { text:"Corrected ASD, VSD, PDA (no residual defects): generally well tolerated" },
    { text:"Tetralogy of Fallot (repaired): moderate risk; depends on residual PR, RV function" },
  ],
  right: [
    { text:"PERIPARTUM CARDIOMYOPATHY (PPCM)", isHeading:true },
    { text:"Definition: LV dysfunction (EF <45%) developing in last month of pregnancy or within 5 months postpartum, with no identifiable cause" },
    { text:"Incidence: 1:1,000–4,000 deliveries; rising (multifetal pregnancy, advanced maternal age, preeclampsia)" },
    { text:"" },
    { text:"RISK FACTORS", isHeading:true },
    { text:"African descent, multiparity, twin pregnancy, preeclampsia, obesity, age >30, tocolvsis with beta-agonists" },
    { text:"" },
    { text:"PATHOPHYSIOLOGY", isHeading:true },
    { text:"Prolactin cleavage (16 kDa fragment) → antiangiogenic → cardiomyocyte apoptosis" },
    { text:"Oxidative stress, autoimmune mechanisms" },
    { text:"" },
    { text:"CLINICAL FEATURES", isHeading:true },
    { text:"Dyspnea, orthopnea, PND, leg edema, fatigue" },
    { text:"May present acutely with cardiogenic shock" },
    { text:"" },
    { text:"MANAGEMENT", isHeading:true },
    { text:"Standard HF therapy: diuretics, hydralazine + nitrates (avoid ACEi/ARB in pregnancy), beta-blockers" },
    { text:"Postpartum: ACEi/ARB, bromocriptine (dopamine agonist — inhibits prolactin cleavage; emerging evidence)" },
    { text:"LMWH anticoagulation (if EF <35%) — thromboembolism risk" },
    { text:"ICD if EF <35% persists after 6 months" },
    { text:"Recovery: ~50% recover EF to normal; risk of recurrence in subsequent pregnancies" },
  ]
}, true);

// S3-5: Pulmonary HTN
contentSlide(pres, "Pulmonary Arterial Hypertension & Arrhythmias in Pregnancy", C.red, [
  { text:"PULMONARY ARTERIAL HYPERTENSION (PAH)", isHeading:true },
  { text:"Definition: mPAP >25 mmHg at rest; PVRI >3 WU·m²" },
  { text:"Maternal mortality: 30–56% (WHO Class IV) — PREGNANCY IS STRONGLY CONTRAINDICATED" },
  { text:"Pathophysiology: fixed elevated PVR → cannot accommodate ↑ CO of pregnancy; right heart failure" },
  { text:"If pregnancy continues: early delivery (34–36 wks) in tertiary center with PAH team" },
  { text:"Medical therapy: PDE-5 inhibitors (sildenafil), prostacyclin analogs (safe), ERA (endothelin receptor antagonists — teratogenic, avoid)" },
  { text:"" },
  { text:"ARRHYTHMIAS IN PREGNANCY", isHeading:true },
  { text:"Most common arrhythmia: Supraventricular tachycardia (SVT) — increased prevalence due to hormonal and autonomic changes" },
  { text:"AF/Flutter: rare, but must exclude structural heart disease; rate vs rhythm control decision" },
  { text:"VT: rare; requires urgent evaluation; amiodarone is last resort (neonatal hypothyroidism, IUGR)" },
  { text:"" },
  { text:"ANTIARRHYTHMIC DRUG SAFETY IN PREGNANCY", isHeading:true },
  { text:"Generally safe: adenosine (SVT), metoprolol, verapamil (caution with AF), digoxin" },
  { text:"Avoid/use with caution: flecainide (limited data), sotalol (fetal QT prolongation), amiodarone (thyroid, IUGR)" },
  { text:"DC cardioversion: SAFE at any gestational age (minimal current reaches fetus)" },
  { text:"" },
  { text:"MYOCARDIAL INFARCTION IN PREGNANCY", isHeading:true },
  { text:"Rare but increasing (0.5–6/100,000 deliveries); most common: 3rd trimester and postpartum" },
  { text:"Mechanism: spontaneous coronary artery dissection (SCAD) most common in peripartum MI" },
  { text:"Management: aspirin safe; P2Y12 inhibitors — caution; primary PCI preferred over thrombolytics" },
]);

// S3-6: Delivery management
contentSlide(pres, "Management of Cardiac Disease: Delivery & Obstetric Medications", C.red, {
  left: [
    { text:"MODE OF DELIVERY", isHeading:true },
    { text:"Vaginal delivery (preferred for most cardiac disease):" },
    { text:"  Less blood loss, avoids surgical stress, hemodynamic stability", indent:1 },
    { text:"  Early ambulation", indent:1 },
    { text:"Elective cesarean (indicated for specific high-risk):" },
    { text:"  Marfan with aortic dilation, severe AS, Eisenmenger (timing)", indent:1 },
    { text:"  Advantage: controlled timing, consultants available", indent:1 },
    { text:"  Risks: major surgery, anesthesia, hemorrhage, infection, PE", indent:1 },
    { text:"" },
    { text:"LABOR MANAGEMENT PRINCIPLES", isHeading:true },
    { text:"Multidisciplinary team: MFM + cardiologist + anesthesiologist + cardiac surgeon on standby" },
    { text:"Monitoring: continuous SpO2, BP, ECG; invasive arterial line for high-risk" },
    { text:"Epidural analgesia: ↓ pain-induced sympathetic activation; PREFERRED (carefully titrated to avoid ↓ SVR)" },
    { text:"Second stage: assisted delivery (forceps/vacuum) to limit Valsalva" },
    { text:"Avoid aortocaval compression (left lateral tilt)" },
  ],
  right: [
    { text:"OBSTETRIC DRUG HEMODYNAMIC EFFECTS", isHeading:true },
    { text:"Oxytocin (Syntocinon):" },
    { text:"  Bolus IV → ↓ SVR, tachycardia, hypotension — use slow infusion", indent:1 },
    { text:"Ergometrine / Methylergonovine (Methergine):" },
    { text:"  ↑ PVR & SVR → CONTRAINDICATED in PAH, pulmonary HTN, mitral stenosis", indent:1 },
    { text:"Carboprost (prostaglandin F2α):" },
    { text:"  ↑ pulmonary & systemic vascular resistance — AVOID in PAH, severe MS", indent:1 },
    { text:"Beta-agonist tocolytics (terbutaline, ritodrine):" },
    { text:"  Tachycardia → AVOID in mitral/aortic stenosis", indent:1 },
    { text:"" },
    { text:"CARDIAC ARREST IN PREGNANCY", isHeading:true },
    { text:"Activate maternal cardiac arrest team including neonatal team" },
    { text:"Supine position on backboard; hands slightly higher on sternum" },
    { text:"Manual left uterine displacement (NOT tilt — compromises compressions)" },
    { text:"Defibrillate — same energy as non-pregnant; disconnect fetal scalp electrode" },
    { text:"IV/IO access above diaphragm; usual ALS drug doses" },
    { text:"PERIMORTEM CESAREAN SECTION within 5 minutes if no ROSC" },
    { text:"Consider ECMO/CPB if no ROSC" },
  ]
}, true);

// ─── COMPARISON TABLE ────────────────────────────────────────────────────────
tableSlide(pres, "Differential Diagnosis: Liver Diseases Unique to Pregnancy", C.teal,
  ["Condition", "Trimester", "Key Labs", "Key Feature", "Treatment"],
  [
    ["Hyperemesis Gravidarum", "1st (<16 wks)", "Mild ↑ ALT, ↑ Bilirubin, ↓ K⁺", "Severe vomiting, dehydration; no jaundice", "Hydration, antiemetics, TPN if severe"],
    ["ICP", "2nd–3rd", "↑ Bile acids, ↑ ALT", "Pruritus (palms/soles), no rash", "UDCA; deliver ~37-38 wks"],
    ["HELLP", "2nd–3rd (28–36 wks)", "↓ Platelets, ↑ LDH, ↑ AST", "HTN, proteinuria, epigastric pain", "MgSO₄; delivery"],
    ["AFLP", "3rd (>30 wks)", "↑ PT, ↓ Glucose, ↑ WBC, ↑ Cr", "Encephalopathy, hypoglycemia", "ICU + immediate delivery"],
    ["Preeclampsia (liver)", "2nd–3rd", "Variable ↑ ALT; mild", "Hypertension + proteinuria", "Antihypertensives; delivery"],
  ]
);

// ─── SUMMARY SLIDE ───────────────────────────────────────────────────────────
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    { x:0.3, color:C.teal,   label:"LIVER",   points:["Up to 3% of pregnancies — abnormal LFTs\nICP: UDCA + deliver @37–38wks; bile acids >40 = high fetal risk\nHELLP: microangiopathy — definitive Rx = DELIVERY\nAFLP: LCHAD deficiency link — immediate delivery + ICU\nHepatitis E: 20–25% mortality in pregnancy (fulminant)"] },
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    { x:8.9, color:C.red,    label:"HEART",   points:["Leading indirect cause of maternal death\nNYHA III/IV + PAH/Marfan/Eisenmenger = very high risk\nMitral stenosis: rate control + PMC if severe\nPPCM: EF <45%; bromocriptine post-delivery; 50% recover\nPerimortem CS within 5 min of cardiac arrest"] },
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