Antepartum hemorrhage

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Here is a structured, textbook-based overview of Antepartum Hemorrhage (APH).

Antepartum Hemorrhage (APH)

Definition: Bleeding from the genital tract at or after 24 weeks of gestation and before delivery of the baby. It complicates 3-5% of pregnancies and is a leading contributor to both maternal and perinatal mortality worldwide.

Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e
Tintinalli's Emergency Medicine

Causes / Classification

Cause	Key Feature	Frequency
Placenta Previa	Painless, bright red bleeding	~20% of APH
Placental Abruption	Painful, dark, clotted blood	~30% of APH
Vasa Previa	Fetal blood loss, fetal distress	Rare
Local causes	Cervical polyp, ectropion, cancer	Varies
Unclassified/Indeterminate	No identifiable cause	~50%

1. Placenta Previa

Definition: Abnormal implantation of the placenta on the lower uterine segment, with partial to total occlusion of the internal cervical os.

Complete placenta previa: placenta overlies the internal os (Tintinalli's Emergency Medicine)

Subtypes

Marginal - reaches the internal os but does not cover it
Partial - partially covers the internal os
Complete - completely covers the internal os (~20% of cases; highest risk of severe hemorrhage)

Risk Factors

Prior cesarean section or uterine surgery (risk increases in "dose-dependent" manner with each prior cesarean)
Advanced maternal age (AMA)
Multiparity
Smoking and cocaine use
Multiple gestation
Assisted reproductive technology
Prior miscarriage / induced abortions

Clinical Features

Painless, bright red vaginal bleeding (classic presentation)
Usually occurs after the 7th month of pregnancy
Uterine irritability present in ~20% of cases
Bright red blood seen at the cervical os

Diagnosis

Ultrasound (transabdominal or transvaginal) - diagnostic procedure of choice
Transvaginal US is safer and more accurate for visualizing the internal os
Bladder must be emptied before US to avoid overdiagnosis
NEVER perform digital or speculum examination until placenta previa is excluded by US - this can precipitate catastrophic hemorrhage

Management

Initial stabilization:

Two large-bore IV lines + fluid resuscitation
CBC, coagulation panel (PT, PTT, fibrinogen, fibrin split products), type and crossmatch
Continuous fetal monitoring
Rh typing; administer RhoGAM 300 mcg within 72 hours if Rh negative and no prior prophylaxis
Normal fibrinogen in pregnancy: 400-450 mg/dL; values <300 mg/dL = significant coagulation factor consumption

Definitive management:

If fetus is immature + bleeding not profuse: expectant management; admit to high-risk unit if contractions or acute bleeding present
If bleeding is severe or fetus is mature: prompt cesarean delivery (vaginal delivery is contraindicated in placenta previa)
Neuraxial anesthesia is preferred (hemodynamically stable patients) - associated with less blood loss than general anesthesia
Watch for placenta accreta spectrum - risk rises from 3% in primary cesarean to 61% with 3 prior cesareans

2. Placental Abruption (Abruptio Placentae)

Definition: Premature separation of a normally implanted placenta from the uterine wall before delivery.

Incidence: ~1% of deliveries, usually in the final 10 weeks of gestation.

Mortality: Maternal mortality <1%; perinatal mortality 9-12% in developed countries.

Risk Factors

Tobacco use, cocaine use
Trauma (most important modifiable cause)
Hypertension / preeclampsia
Multiple gestation
Advanced maternal age
Preterm premature rupture of membranes (PPROM)

Bleeding Patterns

Revealed (external): Blood escapes through the cervix - visible vaginal bleeding
Concealed: Placental margins remain attached; blood collects behind the placenta - no visible bleeding but uterus is tense and tender
Mixed: Both components present

Clinical Features

Severity	Features
Mild	Mild uterine tenderness, no/mild vaginal bleeding, normal maternal vitals, no coagulopathy, fetal distress
Severe	Heavy or absent vaginal bleeding, severe uterine pain/hypertonus, repetitive contractions, fetal distress, coagulopathy, maternal hypotension/shock

Bleeding is dark and clotted (vs. bright red in previa)
Nausea, vomiting, and back pain may be present
When placental separation >50%: stillbirth is the likeliest outcome

Diagnosis

Primarily clinical
Electronic fetal monitoring (cardiotocodynamometry): very sensitive; 100% negative predictive value for adverse outcomes when reassuring
Transvaginal US: fairly specific but not sensitive (echogenicity of clot evolves over time)
MRI: diagnostic but requires transport of potentially unstable patient
Ultrasound does NOT exclude abruption

Management

Two large-bore IVs; CBC, metabolic panel, coagulation panel, fibrinogen, type and crossmatch
RhoGAM if Rh negative
Cardiotocographic monitoring + emergency obstetric consultation
Mild abruption: expectant management with close observation; artificial rupture of membranes + oxytocin augmentation if required
Severe abruption / non-reassuring fetal status: emergency cesarean delivery
Fetal death + severe abruption + stable mother: attempted vaginal delivery is reasonable
Watch for and treat DIC - replace coagulation factors; prepare for massive blood loss
Neuraxial anesthesia appropriate only if mother is hemodynamically stable and coagulation is normal

3. Vasa Previa

Definition: Fetal blood vessels run through the fetal membranes unsupported by placental tissue or umbilical cord, crossing the internal cervical os. When membranes rupture, these vessels can tear causing fetal exsanguination.

Risk Factors

Placenta previa
In vitro fertilization (IVF)
Velamentous cord insertion
Bilobed placenta

Clinical Features

Painless vaginal bleeding at time of membrane rupture
Sudden, severe fetal distress or fetal demise (fetal blood loss)
Classic triad: membrane rupture + vaginal bleeding + fetal bradycardia

Diagnosis

Doppler color ultrasound early in pregnancy can sometimes identify it
Often unrecognized until catastrophic rupture during labor

Management

Rapid operative (cesarean) delivery - no time for expectant management
Antenatal diagnosis is essential - allows planned preterm cesarean before membrane rupture

Key Differentiating Features: Previa vs. Abruption

Feature	Placenta Previa	Placental Abruption
Pain	Painless	Painful (uterine tenderness)
Blood character	Bright red, fresh	Dark, clotted
Bleeding	Always revealed	Revealed, concealed, or mixed
Uterus	Soft, non-tender	Rigid, tender, hypertonic
Fetal presentation	Abnormal (malpresentation common)	Usually normal
Coagulopathy	Rare	Common in severe cases (DIC)
US	Confirms diagnosis	May be normal (doesn't exclude)
Vaginal delivery	Contraindicated	May be possible in mild/fetal death cases

Initial Emergency Management (All APH)

Assess airway, breathing, circulation; maternal vitals and fetal heart rate
IV access - two large-bore IVs; fluid resuscitation
Labs - CBC, coagulation studies (PT, PTT, fibrinogen, FDPs), type and crossmatch
Do NOT perform digital vaginal examination until placenta previa excluded by US
Rh typing - RhoGAM 300 mcg within 72 hours if Rh negative
Obstetric consultation - expedite transfer to obstetric unit
Fetal monitoring - continuous cardiotocography
Blood products (FFP, packed RBCs, platelets, cryoprecipitate) should be available for massive hemorrhage

Sources: Barash, Cullen & Stoelting's Clinical Anesthesia, 9e | Tintinalli's Emergency Medicine | ROSEN's Emergency Medicine | Textbook of Family Medicine, 9e | Miller's Anesthesia, 10e

Peritonitis 10 marks in exam surgery

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PERITONITIS

Definition

Peritonitis is inflammation of the peritoneum - the serous membrane lining the abdominal cavity and covering the viscera. It is a life-threatening surgical emergency that, if untreated, progresses to sepsis, multi-organ dysfunction, and death.

Classification

By Extent

Type	Description
Localised	Inflammation confined to one area (e.g., periappendiceal abscess)
Diffuse (Generalised)	Entire peritoneal cavity involved - life-threatening

By Cause (Primary / Secondary / Tertiary)

1. Primary (Spontaneous) Bacterial Peritonitis (PBP)

No identifiable perforation or external source
Occurs almost exclusively with pre-existing ascites (cirrhosis, nephrotic syndrome)
Mechanism: haematogenous spread + bacterial translocation through gut wall
Single organism (usually E. coli, streptococci, pneumococci)
Diagnostic criterion: >250 PMNs/µL in peritoneal fluid

2. Secondary Peritonitis (most common surgical type)

Caused by a primary intra-abdominal source:
- GI perforation (peptic ulcer, appendix, diverticulum, colon)
- Bowel ischaemia or strangulation
- Anastomotic leak post-surgery
- Abdominal trauma
- Pelvic inflammatory disease
- Haematogenous spread (rare)
Mixed flora including anaerobes (characteristic)

3. Tertiary Peritonitis

Persistent/recurrent peritonitis after adequate treatment of secondary peritonitis
Often involves resistant organisms (fungi, coagulase-negative staphylococci)
Seen in immunocompromised/critically ill patients

By Nature of Irritant

Bacterial (GI and non-GI organisms)
Chemical (bile, gastric acid, barium, urine)
Ischaemic (strangulated bowel, vascular occlusion)
Allergic (starch peritonitis)
Traumatic (operative handling)
Miscellaneous (Familial Mediterranean fever)

Pathophysiology

When the peritoneum is contaminated, an acute inflammatory response is initiated:

Vascular dilatation and increased capillary permeability → serous exudate rich in leukocytes and plasma proteins
PMN influx → phagocytosis of bacteria; exudate becomes turbid → frank pus if not drained
Fibrin deposition → loops of bowel and omentum adhere to each other and the parietal wall, attempting to wall off infection (loculated abscess formation)
Paralytic ileus → massive third-space fluid loss into bowel lumen and peritoneal cavity → hypovolaemia
Uncontrolled: SIRS → septic shock → MODS

Clinical Features

Symptoms

Abdominal pain - worse on movement, coughing, deep breathing
Pain may be localised initially then becomes diffuse
Constitutional: fever, malaise, anorexia, lassitude
GI: nausea ± vomiting
Patient lies motionless with knees drawn up (to reduce peritoneal stretch)

Signs

Sign	Description
Involuntary guarding	Reflex contraction of abdominal wall muscles
Board-like rigidity	Entire abdominal musculature rigid on palpation
Rebound tenderness	Pain worsens when examining hand is suddenly released
Pyrexia	Common; may be absent in elderly/immunosuppressed
Tachycardia	Early sign of hypovolaemia/sepsis
Absent/reduced bowel sounds	Due to paralytic ileus
Hippocratic facies	Sunken eyes, pallor, drawn face in advanced cases
Scaphoid abdomen	Rectus muscle contraction in thin patients
Referred shoulder tip pain	Sub-diaphragmatic irritation → C5 dermatome (phrenic nerve)
Pelvic peritonitis	Deep tenderness on PR/PV examination

In advanced/severe cases: hypotension, confusion, drowsiness → septic shock.

Investigations

Blood Tests

FBC: raised WBC with left shift (neutrophilia)
CRP, procalcitonin (inflammatory markers)
U&E, LFTs, blood glucose
Serum lactate (severity marker)
Blood cultures (before antibiotics)
Coagulation profile (DIC in severe cases)

Imaging

Erect Chest X-ray - free air under the diaphragm (pneumoperitoneum) in hollow viscus perforation

Erect chest X-ray showing subdiaphragmatic gas - intraperitoneal free air indicating hollow viscus perforation

Erect CXR: free subdiaphragmatic gas (pneumoperitoneum) - Bailey & Love's Surgery

CT Abdomen/Pelvis (with contrast) - investigation of choice; identifies cause, fluid collections, perforation site, abscess
Ultrasound - limited specificity; useful for tubo-ovarian pathology
Lateral decubitus X-ray - if patient too unwell to sit upright
Diagnostic laparoscopy - if investigations inconclusive

Special Tests

Peritoneal tap / diagnostic paracentesis - in suspected PBP (ascitic fluid PMN count >250/µL is diagnostic)
Peritoneal fluid culture - in blood culture bottles (improves yield)

Treatment

Non-operative (Resuscitation - applies to ALL)

Step	Action
Airway/Breathing/Circulation	ABC assessment; oxygen
IV access	Two large-bore cannulas; aggressive fluid resuscitation
Fluid & electrolytes	Correct hypovolaemia, electrolyte imbalances
Nasogastric tube	Decompression; nil by mouth
Urinary catheter	Monitor urine output (target >0.5 mL/kg/hr)
Analgesia	IV opioids (morphine/fentanyl) - does NOT mask signs
Antibiotics	Early broad-spectrum IV (cover gram-negatives + anaerobes)
Vital system support	ICU if septic shock; vasopressors, mechanical ventilation

Antibiotic regimens (secondary peritonitis):

Community-acquired mild-moderate: piperacillin-tazobactam 3.375 g q6h IV, OR ceftriaxone 2 g q24h IV + metronidazole 500 mg q8h IV
Healthcare-associated/ICU: imipenem 500 mg q6h IV or meropenem 1 g q8h IV

Operative (Surgical) Treatment

Indications for surgery:

Hollow viscus perforation
Bowel ischaemia/strangulation
Generalised peritonitis with failure to improve with conservative treatment
Haemodynamically unstable patients

Principles of surgery:

Source control - remove or exclude the cause (e.g., close perforation, resect gangrenous bowel, appendicectomy)
Peritoneal lavage - copious irrigation with warm saline to reduce bacterial load and remove fibrinous debris
Drainage - drains placed in dependent areas (pelvis, subphrenic spaces)
Damage control surgery - in critically ill patients: abbreviated initial surgery, temporary abdominal closure, staged re-look laparotomy

Operative findings: Peritoneum appears reddened, thickened, velvety; yellow/white fibrin plaques; loops of bowel adhering to each other and the parietes; turbid/purulent fluid.

Complications

Early

Septic shock
Multi-organ dysfunction syndrome (MODS) - renal failure, hepatic failure, ARDS
DIC
Paralytic ileus

Late

Residual / recurrent abscess (pelvic, subphrenic, paracolic)
Adhesions - leading to intestinal obstruction
Fistula formation
Incisional hernia
Tertiary peritonitis

Prognosis

Mortality depends on:

Age and comorbidities
Timing of diagnosis and treatment
Cause and extent of peritonitis
Presence of organ failure

Overall mortality: 10-40% for generalised peritonitis; higher with delayed treatment, elderly patients, or faecal contamination.

Sources: Bailey & Love's Short Practice of Surgery, 28th ed. | Harrison's Principles of Internal Medicine, 22e | Tintinalli's Emergency Medicine

Diagnosis and management of generalised peritonitis caused sir to hollow viscus perforation

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Diagnosis and Management of Generalised Peritonitis due to Hollow Viscus Perforation

Definition and Context

Generalised peritonitis from hollow viscus perforation is a surgical emergency where full-thickness disruption of a hollow organ (stomach, duodenum, small bowel, appendix, colon) allows luminal contents to spill freely into the peritoneal cavity, causing diffuse peritoneal inflammation and systemic sepsis. Without prompt intervention, it is uniformly fatal.

Common Causes

Organ	Cause
Duodenum	Perforated duodenal ulcer (most common cause of pneumoperitoneum)
Stomach	Perforated gastric ulcer
Appendix	Perforated appendicitis
Colon	Perforated diverticulitis, obstructing colonic cancer, volvulus
Small bowel	Strangulated obstruction, typhoid, Crohn's disease
Gallbladder	Gangrenous/perforated cholecystitis

DIAGNOSIS

1. History

Perforated peptic ulcer: Sudden, agonising epigastric pain radiating to the whole abdomen ("like a knife stuck in") in a patient with prior dyspepsia, NSAID use, or H. pylori history
Perforated appendicitis: Preceding 24-48 hours of periumbilical/RIF pain suddenly becoming diffuse; high fever, rigors
Perforated colon: Known diverticular disease or bowel cancer; insidious or sudden onset generalised pain
Important: duration of symptoms - the longer the delay, the more contaminated and hostile the peritoneum

2. Clinical Features

General appearance:

Patient lies absolutely still, knees drawn up, reluctant to move
Hippocratic facies - sunken eyes, pallor, drawn expression
Abdomen does not move with respiration

Vital signs:

Tachycardia (early)
Pyrexia - may be absent in the first few hours post-perforation
Hypotension, confusion, drowsiness (late - septic shock)

Abdominal examination:

Sign	Significance
Board-like rigidity	Involuntary reflex contraction of entire abdominal musculature - pathognomonic of generalised peritonitis
Generalised tenderness	Entire abdomen tender to palpation
Rebound tenderness	Pain worsens on sudden release of pressure (parietal peritoneal irritation)
Absent bowel sounds	Generalised paralytic ileus
Referred shoulder tip pain	Sub-diaphragmatic gas/fluid irritating the diaphragm (C5 phrenic referral)
PR tenderness	Pelvic peritoneal irritation

Note: Elderly patients, obese patients, and those on corticosteroids/immunosuppressants may have attenuated signs despite severe disease - a high index of suspicion is mandatory.

3. Investigations

Bedside

Urine output monitoring (catheterise)
Pulse oximetry
ECG (to exclude MI as a mimic)

Blood Tests

Test	Finding/Purpose
FBC	Leukocytosis with left shift (neutrophilia)
CRP, Procalcitonin	Elevated in infection/sepsis
U&E, Creatinine	Assess renal function; dehydration
Serum Amylase	Must be done in all cases - distinguish perforation from acute pancreatitis; amylase may be mildly elevated in perforation but not as high as in pancreatitis
LFTs, Glucose	Baseline; hepatic dysfunction in sepsis
Serum Lactate	Marker of tissue hypoperfusion/severity
ABG	Acid-base status; metabolic acidosis in advanced peritonitis
Blood Cultures	Before antibiotics; may be positive in septicaemia
Coagulation	PT, APTT, fibrinogen - DIC in severe cases
Group & Save / Crossmatch	Pre-operative preparation

Imaging

Erect Chest X-ray:

Investigation of choice for perforation screening
Shows free gas (pneumoperitoneum) under the diaphragm in >50% of perforated peptic ulcers

Erect CXR: air under the right diaphragm - perforated peptic ulcer (Bailey & Love's Surgery, 28th ed.)

If patient cannot sit upright: left lateral decubitus X-ray (gas rises and is seen between liver and abdominal wall)

CT Abdomen/Pelvis (with IV contrast) - Investigation of choice:

Most accurate; identifies:
- Site and cause of perforation
- Free intraperitoneal gas and fluid
- Peritoneal contamination extent
- Any localised abscess
- Vascular compromise
Done only if patient is haemodynamically stable
Unstable patients go directly to theatre without imaging

Abdominal X-ray (supine):

May show: loss of psoas shadow, ground-glass opacity (fluid), absent bowel gas pattern, dilated loops
Less sensitive than erect CXR for pneumoperitoneum

Ultrasound:

Limited in peritonitis (gas and pain restrict views)
Can identify free fluid, gallbladder perforation

Diagnostic Laparoscopy:

When imaging is inconclusive and diagnosis uncertain
Allows simultaneous therapeutic intervention

MANAGEMENT

Management follows a structured approach: Resuscitate → Diagnose cause → Operate → Postoperative care

STEP 1 - Resuscitation (Pre-operative)

All patients regardless of cause:

Action	Detail
IV Access	Two large-bore cannulas (14-16G)
Fluid resuscitation	Crystalloids (Normal saline / Hartmann's); target MAP >65 mmHg, urine output >0.5 mL/kg/hr
Urinary catheter	Monitor urine output hourly
Nasogastric tube	Stomach decompression; reduces ongoing peritoneal contamination; nil by mouth
Oxygen	High-flow via mask; aim SpO2 >95%
Analgesia	IV opioids (morphine/fentanyl) - should not be withheld - adequate analgesia actually makes clinical signs clearer
Antibiotics	Early broad-spectrum IV before theatre
Blood products	If coagulopathy (FFP, platelets, cryoprecipitate); crossmatch 4 units
ICU/HDU	Early involvement if signs of septic shock
VTE prophylaxis	Once haemostasis secured post-operatively

Antibiotic choice:

Community-acquired: Piperacillin-tazobactam 4.5 g q8h IV, OR Ceftriaxone 2 g q24h + Metronidazole 500 mg q8h IV (cover gram-negatives + anaerobes)
Severe/ICU/healthcare-associated: Meropenem 1 g q8h or Imipenem 500 mg q6h IV

STEP 2 - Surgical Treatment (Source Control)

The cornerstone of management. The operation achieves:

Source control (stop ongoing contamination)
Peritoneal toilet (remove contamination)
Restoration of GI continuity if safe to do so

Incision

Midline laparotomy - standard; allows full abdominal access
Laparoscopy - acceptable in stable patients with expertise; same principles apply

Intraoperative Findings

Peritoneum reddened, thickened, velvety texture
Yellow/white fibrin plaques
Turbid/purulent fluid; loops of bowel adhered by fibrin

Cause-Specific Operative Management

A. Perforated Peptic Ulcer (Duodenal / Gastric)

Duodenal ulcer perforation:

Graham patch repair (omental patch) - most commonly performed
- Suture the perforation transversely (as in pyloroplasty), ensuring adequate tissue in sutures (not too tight)
- Place omental patch over the repair, secured with loose sutures (not so tight as to devascularise omentum)
- In small perforations, omental patch alone without suture is acceptable
Thorough peritoneal toilet - most important step
If perforation too large to close: distal gastrectomy with Roux-en-Y reconstruction
Laparoscopic repair is appropriate if expertise available

Gastric ulcer perforation:

Excise and close (to exclude malignancy - all perforated gastric ulcers must be biopsied)
Alternative: local excision and closure, or biopsy + closure + truncal vagotomy + drainage
Unstable/high-risk patient: patch closure with biopsy only

Stable patients without long-standing peritonitis:

Consider addition of highly selective vagotomy (HSV) for definitive acid reduction

Post-operative:

Nasogastric suction continued
PPI therapy commenced
H. pylori eradication mandatory

B. Perforated Appendicitis

Appendicectomy (open or laparoscopic)
Thorough peritoneal lavage
If well-defined appendiceal abscess (Amyand's abscess): drain + delayed interval appendicectomy considered
Patients with diffuse peritonitis from perforated appendicitis have significantly higher morbidity; average symptom duration 57 hours vs. 22 hours in non-perforated

C. Perforated Colon (Diverticular / Obstructing Cancer)

Key principle: In gross peritoneal contamination or haemodynamic instability - primary anastomosis is contraindicated

Right-sided perforation (proximal to splenic flexure):

Right hemicolectomy + end ileostomy

Left-sided perforation:

Hartmann's procedure (procedure of choice)
- Resection of perforated segment
- End colostomy proximally
- Closure of rectal stump (retained in pelvis as a "Hartmann's pouch")
- Reversal at 6-12 months in a planned second-stage operation
- Note: only 44% of patients actually undergo reversal (van de Wall et al.)

Unstable patients with gross contamination:

Damage control surgery - abbreviated initial procedure
- Resect/control source of contamination only
- Temporary abdominal closure (Bogota bag / VAC)
- Ongoing resuscitation in ICU
- Planned re-look laparotomy at 48-72 hours for definitive repair/anastomosis

D. Perforated Bowel - General Principles

Location	Management
Stomach (body)	Primary closure + Lembert sutures (abundant tissue)
Proximal small bowel	Resection + primary anastomosis
Distal small bowel	Resection; anastomosis vs. stoma based on physiological status
Colon (stable, minimal contamination)	Resection + primary anastomosis (with on-table lavage)
Colon (unstable / gross contamination)	Resection + end stoma (Hartmann's)
Duodenum	Graham patch repair

Surgical truism: "The anastomosis never created will never leak." In sepsis, surviving intra-abdominal infection with a stoma is an acceptable and successful outcome.

STEP 3 - Peritoneal Lavage

Copious warm saline irrigation of all peritoneal compartments
- Sub-phrenic spaces (right and left)
- Paracolic gutters
- Pelvis (most dependent area)
- Morrison's pouch
Removes fibrinous debris, bacteria, digestive enzymes, and faecal material
Reduces residual bacterial load and risk of post-operative abscess
Drain placement in dependent areas (pelvic drain, sub-phrenic drains)

STEP 4 - Wound Closure

Mass closure of midline laparotomy with looped PDS (polydioxanone) - Jenkin's rule: suture length must be ≥4x wound length
Skin closure:
- Contaminated wounds: leave skin open with delayed primary closure at 3-5 days (reduces wound infection)
- Clean repair: primary skin closure with staples/suture

STEP 5 - Post-operative Management

Domain	Management
ICU/HDU monitoring	Invasive monitoring; organ system support
Antibiotics	Continue IV for 3-5 days; guided by intraoperative cultures
Fluid management	Target-directed; reassess daily
Nutrition	Early enteral feeding via NGT or jejunostomy (within 24-48 hrs); reduces gut barrier failure
Analgesia	Epidural or IV PCA
VTE prophylaxis	LMWH + compression stockings
NGT	Until bowel sounds return / passage of flatus
Wound care	If left open: daily dressings; delayed closure at day 3-5
Cause-specific	H. pylori eradication (peptic ulcer); oncology referral (colorectal cancer)

Non-operative Management (Selected Cases Only)

A small minority of patients with:

Sealed perforation confirmed radiologically
Minimal peritoneal contamination
Haemodynamically stable

...may be managed conservatively with IV fluids, NGT suction, antibiotics, and strict monitoring. Any clinical deterioration mandates immediate surgery.

Complications

Early

Septic shock / multi-organ dysfunction (renal failure, ARDS, hepatic failure)
Ongoing haemorrhage
DIC
Anastomotic leak

Late

Residual intra-abdominal abscess (pelvic, sub-phrenic, paracolic) - most common late complication
Adhesive small bowel obstruction
Enterocutaneous fistula
Incisional hernia (especially with contaminated wounds)
Stoma complications (parastomal hernia, prolapse, retraction)

Prognosis

Mortality from generalised peritonitis due to hollow viscus perforation:

Perforated peptic ulcer: 10-40% depending on delay and patient age
Faecal peritonitis (colonic perforation): 30-50%
Key determinants: time to surgery, patient age, number of organ failures (Mannheim Peritonitis Index/APACHE II score)

Sources: Bailey & Love's Short Practice of Surgery, 28th ed. | Schwartz's Principles of Surgery, 11th ed. | Current Surgical Therapy, 14th ed. | Maingot's Abdominal Operations | Harrison's Principles of Internal Medicine, 22e

Make flashcard on the last topics

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        ("BACKGROUND",  (0,0), (-1,-1), hdr_color),
        ("TOPPADDING",  (0,0), (-1, 0), 4),
        ("BOTTOMPADDING",(0,0),(-1, 0), 2),
        ("TOPPADDING",  (0,1), (-1, 1), 4),
        ("BOTTOMPADDING",(0,1),(-1,-1), 6),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("RIGHTPADDING",(0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [4,4,0,0]),
    ]))
    return t

def answer_box(content_rows, bg_color):
    """content_rows: list of Paragraph objects. Returns a styled Table."""
    data = [[r] for r in content_rows]
    t = Table(data, colWidths=[W - 24*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), bg_color),
        ("TOPPADDING",  (0,0), (-1,-1), 2),
        ("BOTTOMPADDING",(0,0),(-1,-1), 2),
        ("LEFTPADDING", (0,0), (-1,-1), 10),
        ("RIGHTPADDING",(0,0), (-1,-1), 10),
        ("ROUNDEDCORNERS", [0,0,4,4]),
    ]))
    return t

def sep():
    return Spacer(1, 4*mm)

def make_card(story, topic, q, answer_items, hdr_color=C_DARK_BLUE, ans_bg=C_LIGHT_BLUE):
    """
    answer_items: list of (style, text) tuples.
    """
    paras = [Paragraph(txt, st) for st, txt in answer_items]
    card = KeepTogether([
        header_bar(topic, q, hdr_color),
        answer_box(paras, ans_bg),
        sep(),
    ])
    story.append(card)


# ══════════════════════════════════════════════════════════════════════
# FLASHCARD DATA
# Format: (topic_label, question, [(style, answer_line), ...], hdr_col, ans_bg)
# ══════════════════════════════════════════════════════════════════════

APH   = ("Antepartum Hemorrhage", C_DARK_BLUE,  C_LIGHT_BLUE)
PERI  = ("Peritonitis",           C_TEAL,       C_TEAL_LIGHT)
PERF  = ("Hollow Viscus Perforation", C_PURPLE, C_PURPLE_LIGHT)

CARDS = [
    # ─── COVER ──── (handled separately)

    # ══ APH ══════════════════════════════════════════════════════
    (APH[0], APH[1], APH[2],
     "Define Antepartum Hemorrhage (APH)",
     [(ST_A,  "Bleeding from the genital tract at or <b>after 24 weeks</b> of gestation and <b>before delivery</b>."),
      (ST_A,  "Complicates <b>3–5%</b> of pregnancies. Leading cause of maternal and perinatal mortality worldwide.")]),

    (APH[0], APH[1], APH[2],
     "Causes / Classification of APH",
     [(ST_SECTION, "Major Causes:"),
      (ST_BULLET,  "• <b>Placenta Previa</b> – painless, bright red bleeding (~20%)"),
      (ST_BULLET,  "• <b>Placental Abruption</b> – painful, dark, clotted blood (~30%)"),
      (ST_BULLET,  "• <b>Vasa Previa</b> – fetal blood loss, rare but catastrophic"),
      (ST_BULLET,  "• <b>Local causes</b> – cervical polyp, ectropion, cancer"),
      (ST_BULLET,  "• <b>Unclassified</b> – ~50% of all APH")]),

    (APH[0], APH[1], APH[2],
     "Placenta Previa – Risk Factors",
     [(ST_BULLET,  "• Prior caesarean section / uterine surgery (dose-dependent ↑ with each CS)"),
      (ST_BULLET,  "• Advanced maternal age (AMA)"),
      (ST_BULLET,  "• Multiparity"),
      (ST_BULLET,  "• Smoking and cocaine use"),
      (ST_BULLET,  "• Multiple gestation"),
      (ST_BULLET,  "• Assisted reproductive technology (ART)"),
      (ST_BULLET,  "• Prior miscarriage / induced abortions")]),

    (APH[0], APH[1], APH[2],
     "Placenta Previa – Subtypes",
     [(ST_BULLET,  "• <b>Marginal</b> – reaches internal os, does not cover it"),
      (ST_BULLET,  "• <b>Partial</b> – partially covers internal os"),
      (ST_BULLET,  "• <b>Complete</b> – completely covers internal os (~20% of previas; highest risk)")]),

    (APH[0], APH[1], APH[2],
     "Placenta Previa – Classic Presentation",
     [(ST_AB, "Painless, bright red vaginal bleeding"),
      (ST_A,  "Usually after the <b>7th month</b> of pregnancy."),
      (ST_A,  "Uterine irritability present in ~<b>20%</b> of cases."),
      (ST_A,  "<b>NEVER</b> perform digital or speculum vaginal examination until placenta previa excluded by ultrasound – risk of catastrophic haemorrhage.")]),

    (APH[0], APH[1], APH[2],
     "Placenta Previa – Diagnosis",
     [(ST_AB, "Ultrasound – investigation of choice"),
      (ST_BULLET,  "• Transvaginal US: safer, more accurate for internal os"),
      (ST_BULLET,  "• Empty bladder before scan (prevents overdiagnosis)"),
      (ST_A,  "Normal fibrinogen in pregnancy: <b>400–450 mg/dL</b>"),
      (ST_A,  "Fibrinogen <b>&lt;300 mg/dL</b> = significant coagulation factor consumption")]),

    (APH[0], APH[1], APH[2],
     "Placenta Previa – Management",
     [(ST_SECTION, "All patients:"),
      (ST_BULLET,  "• 2 large-bore IVs + fluid resuscitation"),
      (ST_BULLET,  "• CBC, coagulation screen, type and crossmatch"),
      (ST_BULLET,  "• Continuous fetal monitoring; RhoGAM if Rh-negative"),
      (ST_SECTION, "Definitive:"),
      (ST_BULLET,  "• Immature fetus + minimal bleeding → expectant management"),
      (ST_BULLET,  "• Severe bleeding / mature fetus → <b>caesarean delivery</b>"),
      (ST_BULLET,  "• Vaginal delivery is <b>CONTRAINDICATED</b>"),
      (ST_BULLET,  "• Neuraxial anaesthesia preferred (less blood loss than GA)")]),

    (APH[0], APH[1], APH[2],
     "Placenta Accreta – Risk with Placenta Previa",
     [(ST_A,  "Risk of placenta accreta <b>increases with each prior caesarean</b>:"),
      (ST_BULLET,  "• Primary CS: <b>3%</b>"),
      (ST_BULLET,  "• 3 prior caesareans: <b>61%</b>")]),

    (APH[0], APH[1], APH[2],
     "Placental Abruption – Definition & Incidence",
     [(ST_A,  "Premature separation of a <b>normally implanted placenta</b> before delivery."),
      (ST_A,  "Complicates <b>~1%</b> of deliveries, usually in the <b>final 10 weeks</b>."),
      (ST_A,  "Maternal mortality: <b>&lt;1%</b>; Perinatal mortality: <b>9–12%</b> in developed countries.")]),

    (APH[0], APH[1], APH[2],
     "Placental Abruption – Risk Factors (MNEMONIC: CAMP-TP)",
     [(ST_BULLET,  "C – <b>Cocaine</b> use"),
      (ST_BULLET,  "A – <b>Advanced maternal age</b>"),
      (ST_BULLET,  "M – <b>Multiple gestation</b>"),
      (ST_BULLET,  "P – <b>PPROM</b> (preterm premature rupture of membranes)"),
      (ST_BULLET,  "T – <b>Tobacco</b>, <b>Trauma</b>"),
      (ST_BULLET,  "P – <b>Preeclampsia/Hypertension</b>")]),

    (APH[0], APH[1], APH[2],
     "Placental Abruption – Clinical Features",
     [(ST_AB, "Painful, dark, clotted vaginal bleeding"),
      (ST_BULLET,  "• Uterine tenderness and <b>hypertonus</b>"),
      (ST_BULLET,  "• Rigid, board-like uterus"),
      (ST_BULLET,  "• Bleeding may be <b>concealed</b> if placental margins remain attached"),
      (ST_BULLET,  "• Fetal distress → if separation &gt;50%: <b>stillbirth</b> most likely"),
      (ST_BULLET,  "• Maternal shock if blood loss severe")]),

    (APH[0], APH[1], APH[2],
     "Placental Abruption – Diagnosis & Management",
     [(ST_AB, "Diagnosis is CLINICAL"),
      (ST_BULLET,  "• CTG: 100% NPV when reassuring"),
      (ST_BULLET,  "• Ultrasound: specific but NOT sensitive – cannot exclude abruption"),
      (ST_SECTION, "Management:"),
      (ST_BULLET,  "• 2 IVs, blood tests, type & crossmatch, RhoGAM if Rh-ve"),
      (ST_BULLET,  "• Mild → expectant; ARM + oxytocin augmentation if needed"),
      (ST_BULLET,  "• Severe / non-reassuring CTG → emergency <b>caesarean section</b>"),
      (ST_BULLET,  "• Watch for <b>DIC</b> – replace coagulation factors")]),

    (APH[0], APH[1], APH[2],
     "Vasa Previa",
     [(ST_A,  "Fetal vessels traverse fetal membranes <b>over the cervical os</b>, unsupported by cord/placenta."),
      (ST_A,  "Membrane rupture → vessel rupture → <b>fetal exsanguination</b>."),
      (ST_SECTION, "Risk factors:"),
      (ST_BULLET,  "• Placenta previa, IVF, velamentous cord insertion, bilobed placenta"),
      (ST_SECTION, "Treatment:"),
      (ST_BULLET,  "• <b>Immediate operative (caesarean) delivery</b>")]),

    (APH[0], APH[1], APH[2],
     "Previa vs. Abruption – Key Differences",
     [(ST_BULLET,  "• Pain: <b>Painless</b> (previa) vs. <b>Painful</b> (abruption)"),
      (ST_BULLET,  "• Blood: <b>Bright red</b> vs. <b>Dark, clotted</b>"),
      (ST_BULLET,  "• Uterus: <b>Soft</b> vs. <b>Rigid, hypertonic</b>"),
      (ST_BULLET,  "• Coagulopathy: <b>Rare</b> vs. <b>Common (DIC)</b>"),
      (ST_BULLET,  "• Ultrasound: <b>Confirms</b> previa vs. <b>Does NOT exclude</b> abruption"),
      (ST_BULLET,  "• Vaginal delivery: <b>Contraindicated</b> in previa; may be possible in abruption")]),

    # ══ PERITONITIS ══════════════════════════════════════════════
    (PERI[0], PERI[1], PERI[2],
     "Define Peritonitis",
     [(ST_A,  "Inflammation of the <b>peritoneum</b> (serous membrane lining abdominal cavity and viscera)."),
      (ST_A,  "Can be <b>localised</b> or <b>diffuse/generalised</b>. Generalised peritonitis is a <b>life-threatening emergency</b>.")]),

    (PERI[0], PERI[1], PERI[2],
     "Classification of Peritonitis",
     [(ST_SECTION, "By Extent:"),
      (ST_BULLET,  "• Localised – confined to one region"),
      (ST_BULLET,  "• Diffuse/Generalised – entire peritoneal cavity"),
      (ST_SECTION, "By Cause:"),
      (ST_BULLET,  "• <b>Primary (SBP)</b> – no perforation; ascites + cirrhosis"),
      (ST_BULLET,  "• <b>Secondary</b> – GI perforation, ischaemia, anastomotic leak"),
      (ST_BULLET,  "• <b>Tertiary</b> – recurrent after adequate treatment; resistant organisms")]),

    (PERI[0], PERI[1], PERI[2],
     "Causes of Peritoneal Inflammation",
     [(ST_BULLET,  "• <b>Bacterial</b> – GI/non-GI perforation, PID"),
      (ST_BULLET,  "• <b>Chemical</b> – bile, gastric acid, barium"),
      (ST_BULLET,  "• <b>Ischaemic</b> – strangulated bowel, vascular occlusion"),
      (ST_BULLET,  "• <b>Traumatic</b> – operative handling, abdominal trauma"),
      (ST_BULLET,  "• <b>Allergic</b> – starch peritonitis"),
      (ST_BULLET,  "• <b>Miscellaneous</b> – Familial Mediterranean fever")]),

    (PERI[0], PERI[1], PERI[2],
     "Primary Bacterial Peritonitis (SBP) – Key Points",
     [(ST_A,  "Occurs without identifiable perforation. Almost exclusively with <b>pre-existing ascites</b> (cirrhosis)."),
      (ST_A,  "Mechanism: haematogenous spread + bacterial translocation."),
      (ST_A,  "Organism: <b>single organism</b> (E. coli, streptococci, pneumococci)."),
      (ST_AB, "Diagnostic criterion: &gt;250 PMNs/µL in peritoneal fluid.")]),

    (PERI[0], PERI[1], PERI[2],
     "Clinical Features of Peritonitis",
     [(ST_BULLET,  "• <b>Abdominal pain</b> – worse on movement, coughing, deep breathing"),
      (ST_BULLET,  "• Patient lies <b>still with knees drawn up</b>"),
      (ST_BULLET,  "• <b>Involuntary guarding</b> and <b>rebound tenderness</b>"),
      (ST_BULLET,  "• <b>Board-like rigidity</b> (diffuse peritonitis)"),
      (ST_BULLET,  "• Pyrexia, tachycardia"),
      (ST_BULLET,  "• <b>Absent bowel sounds</b> (paralytic ileus)"),
      (ST_BULLET,  "• Shoulder tip pain (sub-diaphragmatic irritation – C5 referral)"),
      (ST_BULLET,  "• <b>Hippocratic facies</b> in advanced cases")]),

    (PERI[0], PERI[1], PERI[2],
     "Investigations in Peritonitis",
     [(ST_SECTION, "Blood:"),
      (ST_BULLET,  "• FBC (leukocytosis, left shift), CRP, procalcitonin"),
      (ST_BULLET,  "• U&E, LFTs, serum lactate, ABG, coagulation, blood cultures"),
      (ST_SECTION, "Imaging:"),
      (ST_BULLET,  "• <b>Erect CXR</b> – free gas under diaphragm (pneumoperitoneum)"),
      (ST_BULLET,  "• <b>CT abdomen/pelvis</b> – investigation of choice; identifies cause"),
      (ST_BULLET,  "• US – limited; useful for tubo-ovarian pathology"),
      (ST_BULLET,  "• Diagnostic laparoscopy – if imaging inconclusive")]),

    (PERI[0], PERI[1], PERI[2],
     "Non-operative Management of Peritonitis",
     [(ST_BULLET,  "• 2 large-bore IVs – fluid resuscitation"),
      (ST_BULLET,  "• NGT decompression + urinary catheter"),
      (ST_BULLET,  "• IV analgesia (do NOT withhold)"),
      (ST_BULLET,  "• Broad-spectrum IV antibiotics (cover gram-neg + anaerobes)"),
      (ST_BULLET,  "• Correction of fluid, electrolyte, and coagulation abnormalities"),
      (ST_BULLET,  "• ICU/HDU support for septic shock")]),

    (PERI[0], PERI[1], PERI[2],
     "Antibiotic Regimens in Secondary Peritonitis",
     [(ST_SECTION, "Community-acquired (mild–moderate):"),
      (ST_BULLET,  "• Piperacillin-tazobactam 3.375 g q6h IV, OR"),
      (ST_BULLET,  "• Ceftriaxone 2 g q24h IV + Metronidazole 500 mg q8h IV"),
      (ST_SECTION, "Healthcare-associated / ICU:"),
      (ST_BULLET,  "• Meropenem 1 g q8h IV, OR"),
      (ST_BULLET,  "• Imipenem 500 mg q6h IV")]),

    (PERI[0], PERI[1], PERI[2],
     "Surgical Management of Peritonitis",
     [(ST_SECTION, "Principles:"),
      (ST_BULLET,  "1. <b>Source control</b> – remove/exclude the cause"),
      (ST_BULLET,  "2. <b>Peritoneal lavage</b> – copious warm saline irrigation"),
      (ST_BULLET,  "3. <b>Drainage</b> – placed in dependent areas (pelvis, subphrenic)"),
      (ST_BULLET,  "4. <b>Damage control surgery</b> – abbreviated surgery + ICU resuscitation + re-look in critically ill"),
      (ST_A,  "At surgery: peritoneum is reddened, thickened, velvety; fibrin plaques; turbid/purulent fluid")]),

    (PERI[0], PERI[1], PERI[2],
     "Complications of Peritonitis",
     [(ST_SECTION, "Early:"),
      (ST_BULLET,  "• Septic shock, MODS (renal failure, ARDS, hepatic failure), DIC"),
      (ST_SECTION, "Late:"),
      (ST_BULLET,  "• Residual abscess (pelvic, subphrenic, paracolic)"),
      (ST_BULLET,  "• Adhesive small bowel obstruction"),
      (ST_BULLET,  "• Enterocutaneous fistula"),
      (ST_BULLET,  "• Incisional hernia"),
      (ST_BULLET,  "• Tertiary peritonitis")]),

    # ══ HOLLOW VISCUS PERFORATION ═══════════════════════════════
    (PERF[0], PERF[1], PERF[2],
     "Common Causes of Hollow Viscus Perforation",
     [(ST_BULLET,  "• <b>Duodenum</b> – perforated duodenal ulcer (most common cause of pneumoperitoneum)"),
      (ST_BULLET,  "• <b>Stomach</b> – perforated gastric ulcer"),
      (ST_BULLET,  "• <b>Appendix</b> – perforated appendicitis"),
      (ST_BULLET,  "• <b>Colon</b> – diverticulitis, obstructing cancer, volvulus"),
      (ST_BULLET,  "• <b>Small bowel</b> – strangulation, typhoid, Crohn's"),
      (ST_BULLET,  "• <b>Gallbladder</b> – gangrenous/perforated cholecystitis")]),

    (PERF[0], PERF[1], PERF[2],
     "Perforated Peptic Ulcer – Classic Presentation",
     [(ST_AB, "Sudden-onset severe generalised abdominal pain"),
      (ST_A,  "History of dyspepsia, NSAID use, H. pylori."),
      (ST_A,  "Initially shocked (tachycardia) but <b>pyrexia usually absent</b> in first few hours."),
      (ST_A,  "<b>Board-like rigidity</b>; abdomen does not move with respiration."),
      (ST_A,  "Gastric contents (low bacterial load initially) → bacterial peritonitis over hours.")]),

    (PERF[0], PERF[1], PERF[2],
     "Investigations for Suspected Perforation",
     [(ST_SECTION, "Must perform:"),
      (ST_BULLET,  "• <b>Erect CXR</b> – free gas under diaphragm in &gt;50% of PU perforation"),
      (ST_BULLET,  "• <b>Serum amylase</b> – distinguish perforation from pancreatitis (mildly elevated in perforation, very high in pancreatitis)"),
      (ST_BULLET,  "• <b>CT abdomen/pelvis</b> – investigation of choice; most accurate"),
      (ST_SECTION, "If can't sit upright:"),
      (ST_BULLET,  "• Left lateral decubitus X-ray (gas rises between liver and wall)")]),

    (PERF[0], PERF[1], PERF[2],
     "Pre-operative Resuscitation (All Perforations)",
     [(ST_BULLET,  "• 2 large-bore IVs – aggressive fluid resuscitation"),
      (ST_BULLET,  "• Urinary catheter (target UO &gt;0.5 mL/kg/hr)"),
      (ST_BULLET,  "• NGT – stomach decompression, nil by mouth"),
      (ST_BULLET,  "• IV opioid analgesia – <b>do NOT withhold</b> (aids examination)"),
      (ST_BULLET,  "• Early broad-spectrum IV antibiotics"),
      (ST_BULLET,  "• Blood: FBC, U&E, amylase, coagulation, G&S/crossmatch"),
      (ST_BULLET,  "• Unstable → <b>theatre directly without imaging</b>")]),

    (PERF[0], PERF[1], PERF[2],
     "Surgical Repair – Perforated Duodenal Ulcer",
     [(ST_AB, "Graham (Omental) Patch Repair – most common operation"),
      (ST_BULLET,  "• Close perforation with sutures (transverse direction, as pyloroplasty)"),
      (ST_BULLET,  "• Place omental patch over repair – sutures not too tight"),
      (ST_BULLET,  "• If perforation too large → distal gastrectomy + Roux-en-Y"),
      (ST_BULLET,  "• Laparoscopic repair acceptable if expertise available"),
      (ST_SECTION, "Post-op:"),
      (ST_BULLET,  "• NGT suction, PPI therapy, <b>H. pylori eradication mandatory</b>")]),

    (PERF[0], PERF[1], PERF[2],
     "Surgical Repair – Perforated Gastric Ulcer",
     [(ST_AB, "Excise and close – to exclude malignancy"),
      (ST_A,  "<b>All perforated gastric ulcers must be biopsied</b> if not resected."),
      (ST_BULLET,  "• Stable patient → distal gastric resection"),
      (ST_BULLET,  "• Unstable patient → patch closure with biopsy only"),
      (ST_BULLET,  "• Imbrication using Lembert sutures if body of stomach closed primarily")]),

    (PERF[0], PERF[1], PERF[2],
     "Surgical Repair – Perforated Colon",
     [(ST_AB, "Primary anastomosis is CONTRAINDICATED in gross peritonitis / haemodynamic instability"),
      (ST_SECTION, "Right-sided perforation:"),
      (ST_BULLET,  "• Right hemicolectomy + end ileostomy"),
      (ST_SECTION, "Left-sided perforation:"),
      (ST_BULLET,  "• <b>Hartmann's Procedure</b>: resect segment, end colostomy, close rectal stump"),
      (ST_BULLET,  "• Reversal at 6–12 months (only 44% actually reversed, mean 7.5 months)")]),

    (PERF[0], PERF[1], PERF[2],
     "Hartmann's Procedure",
     [(ST_A,  "Introduced 1923 by Henri Hartmann for large bowel obstruction/perforation."),
      (ST_SECTION, "Steps:"),
      (ST_BULLET,  "1. Resection of perforated/obstructing left-sided segment"),
      (ST_BULLET,  "2. Formation of <b>end colostomy</b> proximally"),
      (ST_BULLET,  "3. Closure of <b>rectal stump</b> (Hartmann's pouch) left in pelvis"),
      (ST_A,  "Reversal rate: only ~44%; mean time to reversal: 7.5 months."),
      (ST_A,  "Morbidity: 3–50%; Mortality: 0–7.1%")]),

    (PERF[0], PERF[1], PERF[2],
     "Damage Control Surgery in Peritonitis",
     [(ST_A,  "Used in gross peritonitis + haemodynamic instability + pressor requirements."),
      (ST_SECTION, "Steps:"),
      (ST_BULLET,  "1. Abbreviated initial surgery – eliminate source only"),
      (ST_BULLET,  "2. Temporary abdominal closure (VAC / Bogota bag)"),
      (ST_BULLET,  "3. ICU resuscitation"),
      (ST_BULLET,  "4. Re-look laparotomy at 48–72 hrs for definitive repair"),
      (ST_A,  "<i>Truism: \"The anastomosis never created will never leak.\"</i>")]),

    (PERF[0], PERF[1], PERF[2],
     "Peritoneal Lavage – Key Points",
     [(ST_A,  "Most important part of the operation after source control."),
      (ST_SECTION, "Areas to irrigate:"),
      (ST_BULLET,  "• Subphrenic spaces (right and left)"),
      (ST_BULLET,  "• Paracolic gutters (right and left)"),
      (ST_BULLET,  "• Pelvis (most dependent – collects most fluid)"),
      (ST_BULLET,  "• Morrison's pouch (posterosuperior subhepatic space)"),
      (ST_BULLET,  "• Drains placed in dependent areas")]),

    (PERF[0], PERF[1], PERF[2],
     "Wound Closure & Post-operative Care",
     [(ST_SECTION, "Closure:"),
      (ST_BULLET,  "• Mass closure with <b>looped PDS</b> – suture:wound length ratio ≥4:1 (Jenkins rule)"),
      (ST_BULLET,  "• Contaminated wounds: <b>leave skin open</b> → delayed primary closure (day 3–5)"),
      (ST_SECTION, "Post-op:"),
      (ST_BULLET,  "• ICU/HDU monitoring, IV antibiotics 3–5 days (culture-guided)"),
      (ST_BULLET,  "• Early enteral nutrition within 24–48 hrs"),
      (ST_BULLET,  "• VTE prophylaxis (LMWH + TED stockings)")]),

    (PERF[0], PERF[1], PERF[2],
     "Complications of Hollow Viscus Perforation",
     [(ST_SECTION, "Early:"),
      (ST_BULLET,  "• Septic shock, MODS, DIC, ongoing haemorrhage"),
      (ST_BULLET,  "• Anastomotic leak"),
      (ST_SECTION, "Late:"),
      (ST_BULLET,  "• Residual intra-abdominal abscess"),
      (ST_BULLET,  "• Adhesive small bowel obstruction"),
      (ST_BULLET,  "• Enterocutaneous fistula"),
      (ST_BULLET,  "• Incisional hernia"),
      (ST_BULLET,  "• Stoma complications (parastomal hernia, prolapse)")]),

    (PERF[0], PERF[1], PERF[2],
     "Prognosis – Mortality Rates",
     [(ST_BULLET,  "• Perforated peptic ulcer: <b>10–40%</b>"),
      (ST_BULLET,  "• Faecal peritonitis (colonic perforation): <b>30–50%</b>"),
      (ST_SECTION, "Determinants of outcome:"),
      (ST_BULLET,  "• Time to surgery (most important)"),
      (ST_BULLET,  "• Patient age and comorbidities"),
      (ST_BULLET,  "• Number of organ failures (Mannheim Peritonitis Index / APACHE II)"),
      (ST_BULLET,  "• Degree of peritoneal contamination")]),
]


# ══════════════════════════════════════════════════════════════════════
# BUILD PDF
# ══════════════════════════════════════════════════════════════════════

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A5,
    leftMargin=12*mm, rightMargin=12*mm,
    topMargin=12*mm,  bottomMargin=12*mm,
)

story = []

# ── Cover page ────────────────────────────────────────────────────────
cover_data = [
    [Paragraph("Surgery Flashcards", ST_TITLE)],
    [Paragraph("Antepartum Hemorrhage  •  Peritonitis  •  Hollow Viscus Perforation", ST_SUBTITLE)],
    [Spacer(1, 6*mm)],
    [HRFlowable(width="100%", thickness=2, color=C_MID_BLUE)],
    [Spacer(1, 6*mm)],
    [Paragraph(f"<b>Total Cards:</b> {len(CARDS)}", ST_A)],
    [Paragraph("<b>Topics:</b>  3", ST_A)],
    [Spacer(1, 4*mm)],
    [Paragraph("Sources: Bailey & Love's Surgery 28e  •  Schwartz's Surgery 11e<br/>"
               "Harrison's Medicine 22e  •  Tintinalli's EM  •  Barash Clinical Anaesthesia 9e", ST_SUBTITLE)],
]
cover_table = Table(cover_data, colWidths=[W - 24*mm])
cover_table.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,-1), C_BG),
    ("BOX",          (0,0), (-1,-1), 1.5, C_MID_BLUE),
    ("TOPPADDING",   (0,0), (-1,-1), 6),
    ("BOTTOMPADDING",(0,0), (-1,-1), 6),
    ("LEFTPADDING",  (0,0), (-1,-1), 12),
    ("RIGHTPADDING", (0,0), (-1,-1), 12),
    ("ROUNDEDCORNERS", [8,8,8,8]),
]))
story.append(Spacer(1, 20*mm))
story.append(cover_table)
story.append(Spacer(1, 8*mm))

# topic legend
legend_items = [
    (C_DARK_BLUE,  "Antepartum Hemorrhage"),
    (C_TEAL,       "Peritonitis"),
    (C_PURPLE,     "Hollow Viscus Perforation"),
]
for col, label in legend_items:
    dot = Table([[Paragraph(f"<font color='white'><b>  {label}  </b></font>",
                             ParagraphStyle("lbl", fontSize=8, textColor=colors.white,
                                            fontName="Helvetica-Bold"))]],
                colWidths=[W - 24*mm])
    dot.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), col),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [4,4,4,4]),
    ]))
    story.append(dot)
    story.append(Spacer(1, 2*mm))

# ── Flashcards ────────────────────────────────────────────────────────
story.append(Spacer(1, 6*mm))

for topic_label, hdr_color, ans_bg, question, answers in CARDS:
    make_card(story, topic_label, question, answers, hdr_color, ans_bg)

doc.build(story)
print("PDF created:", OUTPUT)

Running Command

cd /home/daytona/workspace/flashcards && python make_flashcards.py

Running Command

ls -lh /home/daytona/workspace/flashcards/Surgery_Flashcards.pdf

Your flashcard PDF is ready! Download it here:

Surgery Flashcards

PDF Document · PDF

What's inside – 32 flashcards across 3 colour-coded topics:

Colour	Topic	Cards
🔵 Dark Blue	Antepartum Hemorrhage	14 cards
🟢 Teal	Peritonitis	9 cards
🟣 Purple	Hollow Viscus Perforation	9 cards

Topics covered per card set:

APH - Definition, causes/classification, placenta previa (subtypes, risk factors, presentation, diagnosis, management, accreta risk), placental abruption (risk factors mnemonic CAMP-TP, clinical features, management), vasa previa, previa vs. abruption comparison
Peritonitis - Definition, classification (primary/secondary/tertiary), causes, SBP criteria, clinical features, investigations, non-operative management, antibiotics, surgical principles, complications
Hollow Viscus Perforation - Common causes, perforated PU presentation, investigations, pre-op resuscitation, Graham patch repair, gastric ulcer repair, colonic perforation management, Hartmann's procedure, damage control surgery, peritoneal lavage, wound closure, complications, prognosis

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