"recurrent pregnancy loss" management

recurrent pregnancy loss NEET PG important points high yield 2024 2025

mkdir -p /home/daytona/workspace/neet-pg-qbank && ls /home/daytona/workspace/nee…

~/neet-pg-qbank/generate_qbank.py

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

OUTPUT = "/home/daytona/workspace/neet-pg-qbank/NEET_PG_APS_RPL_QBank.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1A3A5C")
MED_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8F7")
ACCENT      = colors.HexColor("#E8371B")  # answer highlight
GOLD        = colors.HexColor("#F0A500")
PALE_GREY   = colors.HexColor("#F5F5F5")
GREEN       = colors.HexColor("#1E7B34")
ANSWER_BG   = colors.HexColor("#E8F5E9")
VIGNETTE_BG = colors.HexColor("#FFF8E1")
AR_BG       = colors.HexColor("#F3E5F5")

# ── Page number footer ───────────────────────────────────────────────────────
def add_page_number(canvas_obj, doc):
    canvas_obj.saveState()
    canvas_obj.setFont("Helvetica", 8)
    canvas_obj.setFillColor(colors.grey)
    page_num = canvas_obj.getPageNumber()
    canvas_obj.drawCentredString(A4[0] / 2, 1.2 * cm,
                                  f"NEET PG Question Bank  •  APS & RPL Management  •  Page {page_num}")
    canvas_obj.setStrokeColor(MED_BLUE)
    canvas_obj.setLineWidth(0.5)
    canvas_obj.line(2*cm, 1.5*cm, A4[0]-2*cm, 1.5*cm)
    canvas_obj.restoreState()

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

title_style = ParagraphStyle("Title", fontName="Helvetica-Bold", fontSize=22,
                              textColor=colors.white, alignment=TA_CENTER,
                              spaceAfter=4, leading=28)
subtitle_style = ParagraphStyle("Subtitle", fontName="Helvetica", fontSize=11,
                                 textColor=colors.white, alignment=TA_CENTER,
                                 spaceAfter=4)
section_style = ParagraphStyle("Section", fontName="Helvetica-Bold", fontSize=13,
                                textColor=colors.white, alignment=TA_LEFT,
                                spaceAfter=2, leading=18)
q_num_style = ParagraphStyle("QNum", fontName="Helvetica-Bold", fontSize=11,
                              textColor=DARK_BLUE, spaceBefore=6, spaceAfter=2)
q_text_style = ParagraphStyle("QText", fontName="Helvetica", fontSize=10.5,
                               textColor=colors.black, spaceAfter=6,
                               leading=16, alignment=TA_JUSTIFY)
option_style = ParagraphStyle("Option", fontName="Helvetica", fontSize=10,
                               textColor=colors.HexColor("#333333"), spaceAfter=3,
                               leftIndent=16, leading=14)
answer_style = ParagraphStyle("Answer", fontName="Helvetica-Bold", fontSize=10,
                               textColor=GREEN, spaceAfter=2, leading=14)
explanation_style = ParagraphStyle("Explanation", fontName="Helvetica", fontSize=9.5,
                                    textColor=colors.HexColor("#444444"), spaceAfter=4,
                                    leading=14, alignment=TA_JUSTIFY)
bold_exp = ParagraphStyle("BoldExp", fontName="Helvetica-Bold", fontSize=9.5,
                           textColor=DARK_BLUE, spaceAfter=1, leading=14)
vignette_style = ParagraphStyle("Vignette", fontName="Helvetica-Oblique", fontSize=10,
                                 textColor=colors.HexColor("#4A2F00"),
                                 backColor=VIGNETTE_BG,
                                 borderPad=6, spaceAfter=6, leading=15,
                                 alignment=TA_JUSTIFY)
ar_label = ParagraphStyle("ARLabel", fontName="Helvetica-Bold", fontSize=9,
                           textColor=colors.HexColor("#6A1B9A"), spaceAfter=2)
tag_style = ParagraphStyle("Tag", fontName="Helvetica-Oblique", fontSize=8,
                            textColor=colors.grey, spaceAfter=4)

# ── Question data ─────────────────────────────────────────────────────────────
# Format: (type, number, tag, stem/vignette, options_or_None, answer, explanation)
# type: "SBA" | "VIGNETTE" | "AR"
# For AR: stem = (assertion_text, reason_text), options = AR_OPTIONS

AR_OPTIONS = [
    "A. Both A and R are true, and R is the correct explanation of A",
    "B. Both A and R are true, but R is NOT the correct explanation of A",
    "C. A is true but R is false",
    "D. A is false but R is true",
    "E. Both A and R are false",
]

questions = [

# ─── SECTION 1: SBA ───────────────────────────────────────────────────────────
("SBA", 1,
 "SECTION A: Single Best Answer (SBA)",
 "Which of the following is the MOST COMMON cause of first trimester recurrent pregnancy loss?",
 ["A. Uterine anomalies",
  "B. Antiphospholipid syndrome",
  "C. Fetal aneuploidy",
  "D. Cervical incompetence",
  "E. Hyperprolactinemia"],
 "C. Fetal aneuploidy",
 "Fetal aneuploidy accounts for 50-75% of all miscarriage tissue. The most common aneuploidy is autosomal trisomy (~60-70%), followed by monosomy X (~10-20%). This is the single largest known cause of first trimester pregnancy loss."),

("SBA", 2,
 None,
 "A 30-year-old woman has had 3 consecutive first-trimester miscarriages. APS evaluation is positive. The lupus anticoagulant test was positive on two occasions 10 weeks apart. Does this satisfy the laboratory criteria for APS?",
 ["A. Yes - two positive tests are sufficient regardless of interval",
  "B. No - the confirmatory test must be at least 12 weeks after the first",
  "C. No - the test must be repeated 6 months later",
  "D. Yes - lupus anticoagulant alone is sufficient even with single test",
  "E. No - only anticardiolipin antibodies count for APS diagnosis in RPL"],
 "B. No - the confirmatory test must be at least 12 weeks after the first",
 "Sapporo/Sydney criteria require positive aPL antibodies on TWO occasions at least 12 WEEKS apart. A 10-week interval does NOT satisfy criteria. This prevents false positives from transient antibody positivity (e.g., after infection)."),

("SBA", 3,
 None,
 "A woman with APS and recurrent pregnancy loss (no prior thrombosis) becomes pregnant. What is the recommended treatment?",
 ["A. Warfarin + Low-dose aspirin",
  "B. Low-molecular-weight heparin (LMWH) + Low-dose aspirin (LDA)",
  "C. Unfractionated heparin alone",
  "D. Low-dose aspirin alone",
  "E. Prednisolone + aspirin"],
 "B. Low-molecular-weight heparin (LMWH) + Low-dose aspirin (LDA)",
 "For APS without prior thrombosis, the standard of care is prophylactic-dose LMWH + LDA (75-81 mg/day). Warfarin is CONTRAINDICATED in pregnancy (causes warfarin embryopathy: nasal hypoplasia, stippled epiphyses). Aspirin alone is insufficient. Prednisolone has shown harm (increased anomaly rates)."),

("SBA", 4,
 None,
 "Which of the following antiphospholipid antibodies is considered the MOST PREDICTIVE for adverse pregnancy outcome?",
 ["A. Anti-β2 glycoprotein-1 IgM",
  "B. Anticardiolipin IgG",
  "C. Lupus anticoagulant",
  "D. Anti-β2 glycoprotein-1 IgG",
  "E. Anticardiolipin IgM"],
 "C. Lupus anticoagulant",
 "The lupus anticoagulant (LAC) is the most predictive aPL antibody for both thrombosis and adverse pregnancy outcomes. Despite its name, it causes thrombosis (not bleeding) in vivo, by binding phospholipid-binding proteins and activating the coagulation cascade."),

("SBA", 5,
 None,
 "Which thrombophilia testing is RECOMMENDED by ACOG/ASRM in all women with recurrent pregnancy loss?",
 ["A. Factor V Leiden mutation",
  "B. Prothrombin gene mutation G20210A",
  "C. Protein C and S levels",
  "D. MTHFR mutation",
  "E. None of the above - routine thrombophilia screening is NOT recommended"],
 "E. None of the above - routine thrombophilia screening is NOT recommended",
 "ACOG, ASRM, and ESHRE all recommend AGAINST routine inherited thrombophilia testing in women with RPL. Evidence shows testing and treatment with heparin does NOT improve live birth rates in women with inherited thrombophilias. Testing is reserved for women with personal/family history of thrombosis."),

("SBA", 6,
 None,
 "A 28-year-old G3P0+3 (all first trimester losses) has a positive VDRL test. She denies sexual risk factors. Which condition should be suspected?",
 ["A. Syphilis",
  "B. Antiphospholipid syndrome",
  "C. Systemic lupus erythematosus",
  "D. HIV infection",
  "E. Hepatitis C"],
 "B. Antiphospholipid syndrome",
 "APS causes a BIOLOGIC FALSE POSITIVE VDRL/RPR because cardiolipin is used as the antigen in the non-treponemal syphilis test. Anticardiolipin antibodies in APS cross-react with this test. Confirm with FTA-ABS (treponemal test), which will be negative in APS. This is a classic NEET PG trap question."),

("SBA", 7,
 None,
 "What is the minimum number of pregnancy losses before 10 weeks required to satisfy the PREGNANCY MORBIDITY clinical criterion for APS?",
 ["A. 1 unexplained loss",
  "B. 2 unexplained losses",
  "C. 3 or more unexplained consecutive losses",
  "D. 2 or more non-consecutive losses",
  "E. Any number with positive aPL antibodies"],
 "C. 3 or more unexplained consecutive losses",
 "Per Sapporo/Sydney criteria: For losses BEFORE 10 weeks, the threshold is 3 OR MORE consecutive unexplained losses. For losses AT OR AFTER 10 weeks (morphologically normal fetus), even a SINGLE unexplained loss qualifies. This distinction is frequently tested."),

("SBA", 8,
 None,
 "Which of the following uterine anomalies is MOST COMMONLY associated with recurrent pregnancy loss AND is most amenable to surgical correction?",
 ["A. Bicornuate uterus",
  "B. Unicornuate uterus",
  "C. Septate uterus",
  "D. Didelphic uterus",
  "E. Arcuate uterus"],
 "C. Septate uterus",
 "Septate uterus is the most common congenital uterine anomaly causing RPL. The avascular fibromuscular septum impairs implantation and placentation. Treatment: Hysteroscopic metroplasty (resection of septum), which significantly improves live birth rates. Note: Bicornuate uterus is more associated with 2nd trimester losses."),

("SBA", 9,
 None,
 "IVIG (Intravenous Immunoglobulin) has been tried for unexplained RPL. What does current evidence show?",
 ["A. Significant improvement in live birth rates in primary RPL",
  "B. Benefit only in secondary RPL (after at least one live birth)",
  "C. No benefit - RCTs show no difference vs placebo",
  "D. Benefit when combined with prednisolone",
  "E. Benefit only if NK cells are elevated"],
 "C. No benefit - RCTs show no difference vs placebo",
 "A multicenter double-blind RCT and subsequent meta-analysis found NO difference in live birth rates between IVIG and placebo in idiopathic secondary RPL. ASRM and ESHRE do NOT recommend IVIG for RPL. It should only be given in approved research protocols."),

("SBA", 10,
 None,
 "According to the ASRM and ESHRE current definition, recurrent pregnancy loss is defined as:",
 ["A. 3 or more consecutive losses before 20 weeks",
  "B. 2 or more losses before 20 weeks (consecutive or non-consecutive)",
  "C. 3 or more losses before 12 weeks",
  "D. 2 or more losses after fetal cardiac activity seen",
  "E. 3 or more losses before 28 weeks"],
 "B. 2 or more losses before 20 weeks (consecutive or non-consecutive)",
 "ASRM and ESHRE currently define RPL as 2 OR MORE clinically recognized pregnancy losses (ultrasound or histopathologic confirmation). The traditional RCOG definition required 3 or more consecutive losses. The updated definition does not require them to be consecutive and applies before 20 weeks."),

# ─── SECTION 2: CLINICAL VIGNETTES ───────────────────────────────────────────
("VIGNETTE", 11,
 "SECTION B: Clinical Vignettes",
 "A 32-year-old woman presents with her 4th consecutive first trimester miscarriage. Workup reveals: ANA positive (low titer), TSH 3.8 mIU/L, Lupus anticoagulant positive, anticardiolipin IgG 55 GPL (high titer), anti-β2-GP1 negative. The first positive test was 8 weeks ago. Her husband's karyotype is normal. Pelvic MRI shows a normal uterine cavity. What is the MOST APPROPRIATE next step in management?",
 ["A. Start LMWH + aspirin immediately",
  "B. Repeat the aPL antibodies in 4 weeks",
  "C. Repeat the aPL antibodies in at least 4 more weeks (total 12 weeks from first test)",
  "D. Diagnose APS and start warfarin",
  "E. Prescribe prednisolone and aspirin"],
 "C. Repeat the aPL antibodies in at least 4 more weeks (total 12 weeks from first test)",
 "APS diagnosis requires confirmation at least 12 WEEKS after the first positive test. Only 8 weeks have elapsed, so criteria are not yet met. The aPL test must be repeated after the 12-week interval. Starting treatment before confirmed diagnosis could expose the patient to unnecessary anticoagulation risk. Warfarin is absolutely contraindicated in pregnancy."),

("VIGNETTE", 12,
 None,
 "A 27-year-old G2P0+2 is referred for RPL evaluation. Both pregnancies were lost at 8 weeks. Laboratory results: Lupus anticoagulant - positive; Anticardiolipin IgG - 52 GPL; Anti-β2-GP1 IgG - positive. Tests were confirmed 14 weeks later - all remain positive. She is now trying to conceive. She has no history of thrombosis. What is the recommended treatment once pregnancy is confirmed?",
 ["A. Warfarin 5 mg daily",
  "B. Aspirin 75 mg daily alone",
  "C. Unfractionated heparin 5000 units TDS subcutaneously",
  "D. Prophylactic LMWH (e.g., enoxaparin 40 mg/day) + aspirin 75 mg/day",
  "E. Hydroxychloroquine alone"],
 "D. Prophylactic LMWH (e.g., enoxaparin 40 mg/day) + aspirin 75 mg/day",
 "This patient has definite APS (meets all Sydney criteria). Without prior thrombosis, she receives PROPHYLACTIC dose LMWH + LDA during pregnancy, continuing 6-12 weeks postpartum. This woman is also 'triple positive' (LAC + aCL + anti-β2GP1) which confers the highest obstetric risk and strictest management. Warfarin is teratogenic. Aspirin alone is insufficient."),

("VIGNETTE", 13,
 None,
 "A 35-year-old woman is investigated for RPL (3 losses). Her APS panel is negative twice. Parental karyotype: normal. HSG: normal cavity. TSH: 3.0. HbA1c: 5.4%. She has irregular cycles and elevated LH on day 3. Ultrasound shows polycystic ovaries. What is the MOST LIKELY contributing diagnosis and its mechanism of loss?",
 ["A. Premature ovarian insufficiency - low estrogen",
  "B. PCOS - LH hypersecretion leads to premature oocyte maturation and luteal defect",
  "C. Hypothyroidism - low T4 causes luteal phase defect",
  "D. Diabetes mellitus - hyperglycemia causes embryo toxicity",
  "E. Prolactinoma - high prolactin suppresses progesterone"],
 "B. PCOS - LH hypersecretion leads to premature oocyte maturation and luteal defect",
 "PCOS is associated with RPL through multiple mechanisms: (1) LH hypersecretion causes premature oocyte maturation and poor embryo quality; (2) hyperinsulinemia/insulin resistance; (3) hyperandrogenism affecting endometrial receptivity. This patient has classic PCOS features: irregular cycles, elevated LH, PCO morphology. Management includes metformin (reduces miscarriage risk) and weight loss."),

("VIGNETTE", 14,
 None,
 "A 29-year-old woman with 3 unexplained losses presents with positive pregnancy test at 5 weeks. She is desperate to continue the pregnancy. Her GP asks whether progesterone supplementation should be started. What does CURRENT evidence suggest?",
 ["A. Proven benefit - start 400 mg vaginal progesterone twice daily immediately",
  "B. No proven benefit in women with RPL and no current bleeding (PROMISE trial)",
  "C. Proven benefit only if given from conception",
  "D. Progesterone is contraindicated in the first trimester",
  "E. Benefit proven in all RPL patients regardless of bleeding status"],
 "B. No proven benefit in women with RPL and no current bleeding (PROMISE trial)",
 "The PROMISE RCT (Coomarasamy, 2015) randomized women with 3+ prior losses to 400 mg vaginal micronized progesterone twice daily vs placebo from positive pregnancy test. Result: NO significant difference in live birth rates. The PRISM trial (2019) showed benefit specifically in women with 1-2 previous losses WHO ALSO HAD BLEEDING in the current pregnancy. Current recommendation: progesterone is NOT routinely prescribed for RPL without bleeding."),

("VIGNETTE", 15,
 None,
 "A woman with confirmed APS (LAC positive, prior DVT) is now 8 weeks pregnant with her 4th pregnancy (3 previous losses at 9-11 weeks). What anticoagulation regimen is appropriate?",
 ["A. Prophylactic LMWH + aspirin",
  "B. Therapeutic-dose LMWH + aspirin",
  "C. Aspirin alone (prior DVT was treated)",
  "D. Warfarin + aspirin throughout pregnancy",
  "E. Unfractionated heparin prophylaxis only"],
 "B. Therapeutic-dose LMWH + aspirin",
 "For APS patients WITH A HISTORY OF THROMBOSIS, therapeutic-dose (not prophylactic) LMWH + LDA is recommended throughout pregnancy and for 6-12 weeks postpartum. The prior DVT elevates her thrombotic risk category. Warfarin is contraindicated in pregnancy. This distinction (prophylactic vs therapeutic dosing based on thrombosis history) is a key NEET PG differentiator."),

# ─── SECTION 3: ASSERTION-REASON ─────────────────────────────────────────────
("AR", 16,
 "SECTION C: Assertion-Reason",
 ("Assertion (A): Warfarin is contraindicated in pregnancy for management of APS.",
  "Reason (R): Warfarin crosses the placenta and can cause warfarin embryopathy."),
 AR_OPTIONS,
 "A. Both A and R are true, and R is the correct explanation of A",
 "Warfarin crosses the placenta and is teratogenic during weeks 6-12 (organogenesis), causing warfarin embryopathy: nasal hypoplasia, stippled epiphyses (chondrodysplasia punctata), and CNS/eye abnormalities. LMWH is the safe alternative as it does NOT cross the placenta."),

("AR", 17,
 None,
 ("Assertion (A): Lupus anticoagulant prolongs the APTT in vitro but causes thrombosis in vivo.",
  "Reason (R): LAC inhibits phospholipid-dependent coagulation reactions in the test tube, but in vivo it activates platelets and endothelium via β2-glycoprotein-1."),
 AR_OPTIONS,
 "A. Both A and R are true, and R is the correct explanation of A",
 "The paradox of LAC: It inhibits phospholipid-dependent coagulation IN VITRO (prolonged aPTT, DRVVT), but IN VIVO it binds β2-GP1 on cell surfaces, activating platelets, monocytes and endothelial cells - causing a prothrombotic state. This explains why 'anticoagulant' in the name is misleading for clinical management."),

("AR", 18,
 None,
 ("Assertion (A): Approximately 50% of couples evaluated for RPL have no identifiable etiology.",
  "Reason (R): This is because current investigations do not test for all possible causes, and some causes remain scientifically uncharacterized."),
 AR_OPTIONS,
 "A. Both A and R are true, and R is the correct explanation of A",
 "Despite complete evaluation (genetic, anatomic, endocrine, immunologic, thrombophilic workup), at least 50% of RPL couples have no single dominant etiology identified. The reason includes both limitations of current testing and genuinely unknown mechanisms. These couples receive the diagnosis of 'unexplained RPL' and are managed with supportive care."),

("AR", 19,
 None,
 ("Assertion (A): Routine thrombophilia screening (Factor V Leiden, Prothrombin mutation) is recommended in all women with RPL.",
  "Reason (R): Inherited thrombophilias cause placental thrombosis and treatment with heparin significantly improves live birth rates."),
 AR_OPTIONS,
 "E. Both A and R are false",
 "Both the assertion and reason are FALSE. ACOG, ASRM, and ESHRE all RECOMMEND AGAINST routine thrombophilia screening in RPL. Furthermore, meta-analyses (Cochrane review) confirm that heparin treatment does NOT significantly improve live birth rates in women with inherited thrombophilia + RPL without APS. Screening is reserved for personal/family history of thrombosis."),

("AR", 20,
 None,
 ("Assertion (A): A false positive VDRL test in a woman with RPL may indicate APS rather than syphilis.",
  "Reason (R): Cardiolipin is the antigen used in non-treponemal tests for syphilis, and anticardiolipin antibodies in APS cross-react with this test."),
 AR_OPTIONS,
 "A. Both A and R are true, and R is the correct explanation of A",
 "Classic NEET PG question. Non-treponemal tests (VDRL, RPR) use cardiolipin-lecithin-cholesterol antigen. aCL antibodies in APS bind cardiolipin and cause false positivity. Confirm with treponemal test (FTA-ABS, TPHA) - this will be NEGATIVE in APS. Always think APS in a woman with RPL + false positive VDRL."),

]

# ─── PDF BUILD ───────────────────────────────────────────────────────────────
def build_pdf():
    doc = SimpleDocTemplate(
        OUTPUT,
        pagesize=A4,
        topMargin=2.5*cm, bottomMargin=2.2*cm,
        leftMargin=2*cm, rightMargin=2*cm,
        title="NEET PG Question Bank: APS & RPL Management",
        author="Orris Medical AI"
    )

    story = []

    # ── Cover Banner ──────────────────────────────────────────────────────────
    cover_data = [[
        Paragraph("NEET PG QUESTION BANK", title_style),
    ]]
    cover_table = Table(cover_data, colWidths=[17*cm])
    cover_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("ROUNDEDCORNERS", [8]),
        ("TOPPADDING", (0,0), (-1,-1), 18),
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        ("LEFTPADDING", (0,0), (-1,-1), 16),
        ("RIGHTPADDING", (0,0), (-1,-1), 16),
    ]))
    story.append(cover_table)
    story.append(Spacer(1, 0.3*cm))

    sub_data = [[
        Paragraph("Antiphospholipid Syndrome (APS) & Recurrent Pregnancy Loss (RPL) Management", subtitle_style),
    ]]
    sub_table = Table(sub_data, colWidths=[17*cm])
    sub_table.setStyle(TableStyle([
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        ("LEFTPADDING", (0,0), (-1,-1), 16),
        ("RIGHTPADDING", (0,0), (-1,-1), 16),
    ]))
    story.append(sub_table)
    story.append(Spacer(1, 0.4*cm))

    # Stats bar
    stats_data = [["20 Questions", "3 Types", "OB/GYN | Immunology", "July 2026"]]
    stats_table = Table(stats_data, colWidths=[4.25*cm]*4)
    stats_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), LIGHT_BLUE),
        ("FONTNAME", (0,0), (-1,-1), "Helvetica-Bold"),
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        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("GRID", (0,0), (-1,-1), 0.5, MED_BLUE),
        ("ROUNDEDCORNERS", [4]),
    ]))
    story.append(stats_table)
    story.append(Spacer(1, 0.5*cm))

    # Legend
    legend_data = [
        [
            Paragraph("<b>Question Types:</b>", ParagraphStyle("l", fontName="Helvetica-Bold", fontSize=9, textColor=DARK_BLUE)),
            Paragraph("■ SBA = Single Best Answer", ParagraphStyle("l2", fontName="Helvetica", fontSize=9, textColor=colors.black)),
            Paragraph("■ Clinical Vignette = Case-based SBA", ParagraphStyle("l2", fontName="Helvetica", fontSize=9, textColor=colors.black)),
            Paragraph("■ A/R = Assertion-Reason", ParagraphStyle("l2", fontName="Helvetica", fontSize=9, textColor=colors.black)),
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    story.append(legend_table)
    story.append(Spacer(1, 0.8*cm))
    story.append(HRFlowable(width="100%", thickness=1.5, color=MED_BLUE))
    story.append(Spacer(1, 0.5*cm))

    current_section = None

    for idx, q in enumerate(questions):
        qtype, qnum, section_label, stem, options, answer, explanation = q

        items = []

        # Section header
        if section_label and section_label != current_section:
            current_section = section_label
            # Determine background color
            if "A:" in section_label:
                bg = MED_BLUE
            elif "B:" in section_label:
                bg = colors.HexColor("#B85C00")
            else:
                bg = colors.HexColor("#6A1B9A")

            sec_data = [[Paragraph(section_label, section_style)]]
            sec_table = Table(sec_data, colWidths=[17*cm])
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                ("BACKGROUND", (0,0), (-1,-1), bg),
                ("TOPPADDING", (0,0), (-1,-1), 10),
                ("BOTTOMPADDING", (0,0), (-1,-1), 10),
                ("LEFTPADDING", (0,0), (-1,-1), 12),
                ("ROUNDEDCORNERS", [6]),
            ]))
            items.append(sec_table)
            items.append(Spacer(1, 0.4*cm))

        # Question number + type badge
        type_colors = {"SBA": MED_BLUE, "VIGNETTE": colors.HexColor("#B85C00"), "AR": colors.HexColor("#6A1B9A")}
        badge_color = type_colors.get(qtype, MED_BLUE)

        badge_data = [[
            Paragraph(f"<b>Q{qnum}.</b>", q_num_style),
            Paragraph(f"<b>{qtype}</b>", ParagraphStyle("Badge", fontName="Helvetica-Bold",
                      fontSize=8, textColor=colors.white, alignment=TA_CENTER)),
        ]]
        badge_table = Table(badge_data, colWidths=[15.2*cm, 1.8*cm])
        badge_table.setStyle(TableStyle([
            ("BACKGROUND", (1,0), (1,0), badge_color),
            ("ALIGN", (1,0), (1,0), "CENTER"),
            ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
            ("TOPPADDING", (1,0), (1,0), 4),
            ("BOTTOMPADDING", (1,0), (1,0), 4),
            ("ROUNDEDCORNERS", [4]),
        ]))
        items.append(badge_table)

        # Stem / Vignette
        if qtype == "VIGNETTE":
            items.append(Paragraph(stem, vignette_style))
        elif qtype == "AR":
            assertion_text, reason_text = stem
            ar_bg_data = [[
                Paragraph(f"<b>Assertion (A):</b> {assertion_text.replace('Assertion (A): ', '')}", q_text_style),
            ]]
            ar_bg_table = Table(ar_bg_data, colWidths=[17*cm])
            ar_bg_table.setStyle(TableStyle([
                ("BACKGROUND", (0,0), (-1,-1), VIGNETTE_BG),
                ("TOPPADDING", (0,0), (-1,-1), 6),
                ("BOTTOMPADDING", (0,0), (-1,-1), 4),
                ("LEFTPADDING", (0,0), (-1,-1), 10),
            ]))
            items.append(ar_bg_table)

            ar_r_data = [[
                Paragraph(f"<b>Reason (R):</b> {reason_text.replace('Reason (R): ', '')}", q_text_style),
            ]]
            ar_r_table = Table(ar_r_data, colWidths=[17*cm])
            ar_r_table.setStyle(TableStyle([
                ("BACKGROUND", (0,0), (-1,-1), AR_BG),
                ("TOPPADDING", (0,0), (-1,-1), 4),
                ("BOTTOMPADDING", (0,0), (-1,-1), 6),
                ("LEFTPADDING", (0,0), (-1,-1), 10),
            ]))
            items.append(ar_r_table)
            items.append(Spacer(1, 0.2*cm))
        else:
            items.append(Paragraph(stem, q_text_style))

        # Options
        if options:
            for opt in options:
                is_answer = opt.startswith(answer[:2])
                opt_style = ParagraphStyle(
                    "OptHL" if is_answer else "Opt",
                    fontName="Helvetica-Bold" if is_answer else "Helvetica",
                    fontSize=10,
                    textColor=GREEN if is_answer else colors.HexColor("#333333"),
                    leftIndent=16, spaceAfter=3, leading=14,
                )
                items.append(Paragraph(opt, opt_style))

        items.append(Spacer(1, 0.25*cm))

        # Answer box
        ans_data = [[
            Paragraph(f"✓ Correct Answer: {answer}", ParagraphStyle(
                "AnsBox", fontName="Helvetica-Bold", fontSize=10,
                textColor=GREEN)),
        ]]
        ans_table = Table(ans_data, colWidths=[17*cm])
        ans_table.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), ANSWER_BG),
            ("TOPPADDING", (0,0), (-1,-1), 7),
            ("BOTTOMPADDING", (0,0), (-1,-1), 7),
            ("LEFTPADDING", (0,0), (-1,-1), 12),
            ("LINEABOVE", (0,0), (-1,0), 1.5, GREEN),
            ("LINEBELOW", (0,-1), (-1,-1), 1.5, GREEN),
        ]))
        items.append(ans_table)
        items.append(Spacer(1, 0.15*cm))

        # Explanation box
        exp_data = [[
            Paragraph(f"<b>Explanation:</b> {explanation}", explanation_style),
        ]]
        exp_table = Table(exp_data, colWidths=[17*cm])
        exp_table.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), PALE_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 8),
            ("BOTTOMPADDING", (0,0), (-1,-1), 8),
            ("LEFTPADDING", (0,0), (-1,-1), 12),
            ("RIGHTPADDING", (0,0), (-1,-1), 12),
            ("LINEBEFORE", (0,0), (0,-1), 3, MED_BLUE),
        ]))
        items.append(exp_table)
        items.append(Spacer(1, 0.6*cm))

        story.append(KeepTogether(items))

    # ── Back matter: Quick Reference Table ────────────────────────────────────
    story.append(PageBreak())
    story.append(Paragraph("QUICK REFERENCE: APS & RPL Cheat Sheet", ParagraphStyle(
        "CheatTitle", fontName="Helvetica-Bold", fontSize=14, textColor=DARK_BLUE,
        spaceAfter=12, alignment=TA_CENTER)))

    cheat_data = [
        ["Topic", "Key Fact"],
        ["RPL Definition (ASRM/ESHRE)", "2 or more pregnancy losses"],
        ["RPL Definition (Traditional/RCOG)", "3 or more consecutive losses before 20 weeks"],
        ["Most common cause of 1st trimester loss", "Fetal aneuploidy (50-75% of samples)"],
        ["Most common aneuploidy in miscarriage", "Autosomal trisomy (~60-70%)"],
        ["APS lab confirmation interval", "Two tests at least 12 weeks apart"],
        ["Most predictive aPL antibody", "Lupus anticoagulant (LAC)"],
        ["APS treatment (no prior thrombosis)", "Prophylactic LMWH + Low-dose aspirin"],
        ["APS treatment (with prior thrombosis)", "Therapeutic LMWH + Low-dose aspirin"],
        ["Warfarin in pregnancy", "CONTRAINDICATED (embryopathy)"],
        ["False positive VDRL", "Think APS (anticardiolipin antibodies)"],
        ["IVIG for RPL", "No benefit - not recommended"],
        ["Leukocyte immunization for RPL", "Not recommended"],
        ["Thrombophilia screening in RPL", "NOT routinely recommended"],
        ["Most treatable cause of RPL", "Antiphospholipid Syndrome (APS)"],
        ["Best surgical option for septate uterus", "Hysteroscopic metroplasty"],
        ["Unexplained RPL prevalence", "At least 50% of RPL couples"],
        ["PROMISE trial (progesterone)", "No benefit in RPL without bleeding"],
        ["PRISM trial (progesterone)", "Benefit in 1-2 losses WITH bleeding"],
        ["Hydroxychloroquine in APS", "Conditionally recommended (new addition)"],
        ["TSH target in 1st trimester", "< 2.5 mIU/L"],
    ]

    cheat_table = Table(cheat_data, colWidths=[8.5*cm, 8.5*cm])
    cheat_style = TableStyle([
        ("BACKGROUND", (0,0), (-1,0), DARK_BLUE),
        ("TEXTCOLOR", (0,0), (-1,0), colors.white),
        ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE", (0,0), (-1,-1), 9),
        ("FONTNAME", (0,1), (0,-1), "Helvetica-Bold"),
        ("TEXTCOLOR", (0,1), (0,-1), DARK_BLUE),
        ("ALIGN", (0,0), (-1,-1), "LEFT"),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING", (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.white, LIGHT_BLUE]),
        ("GRID", (0,0), (-1,-1), 0.5, colors.HexColor("#AAAAAA")),
        ("LINEBELOW", (0,0), (-1,0), 2, MED_BLUE),
    ])
    cheat_table.setStyle(cheat_style)
    story.append(cheat_table)

    doc.build(story, onFirstPage=add_page_number, onLaterPages=add_page_number)
    print(f"PDF created: {OUTPUT}")

build_pdf()

cd /home/daytona/workspace/neet-pg-qbank && python generate_qbank.py 2>&1

ls -lh /home/daytona/workspace/neet-pg-qbank/NEET_PG_APS_RPL_QBank.pdf