Peripartum Cardiomyopathy (PPCM)

from pptx import Presentation
from pptx.util import Inches, Pt
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.shapes import MSO_SHAPE

NAVY = RGBColor(0x14, 0x23, 0x3F)
ROSE = RGBColor(0xC2, 0x3B, 0x5A)
LIGHT = RGBColor(0xF6, 0xF3, 0xF1)
GREY = RGBColor(0x55, 0x5B, 0x66)
WHITE = RGBColor(0xFF, 0xFF, 0xFF)
SOFT = RGBColor(0xFB, 0xE9, 0xED)
FONT = "Calibri"

prs = Presentation()
prs.slide_width = Inches(13.333)
prs.slide_height = Inches(7.5)
BLANK = prs.slide_layouts[6]


def rect(s, x, y, w, h, fill, shape=MSO_SHAPE.RECTANGLE):
    r = s.shapes.add_shape(shape, Inches(x), Inches(y), Inches(w), Inches(h))
    r.fill.solid()
    r.fill.fore_color.rgb = fill
    r.line.fill.background()
    r.shadow.inherit = False
    return r


def text(s, x, y, w, h, t, size=18, bold=False, color=NAVY, align=PP_ALIGN.LEFT,
         anchor=MSO_ANCHOR.TOP):
    tb = s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.vertical_anchor = anchor
    tf.margin_left = tf.margin_right = Inches(0.05)
    tf.margin_top = tf.margin_bottom = Inches(0.03)
    p = tf.paragraphs[0]
    p.alignment = align
    r = p.add_run()
    r.text = t
    r.font.size = Pt(size)
    r.font.bold = bold
    r.font.color.rgb = color
    r.font.name = FONT
    return tb


def bullets(s, x, y, w, h, items, size=18, color=NAVY, gap=6):
    tb = s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = tf.margin_right = Inches(0.05)
    for i, it in enumerate(items):
        p = tf.paragraphs[0] if i == 0 else tf.add_paragraph()
        p.space_after = Pt(gap)
        if isinstance(it, tuple):
            head, body = it
            r1 = p.add_run()
            r1.text = "\u2022  " + head + " "
            r1.font.bold = True
            r1.font.size = Pt(size)
            r1.font.color.rgb = ROSE
            r1.font.name = FONT
            r2 = p.add_run()
            r2.text = body
            r2.font.size = Pt(size)
            r2.font.color.rgb = color
            r2.font.name = FONT
        else:
            r = p.add_run()
            r.text = "\u2022  " + it
            r.font.size = Pt(size)
            r.font.color.rgb = color
            r.font.name = FONT
    return tb


def content_slide(title, subtitle=None):
    s = prs.slides.add_slide(BLANK)
    bg = s.background.fill
    bg.solid()
    bg.fore_color.rgb = WHITE
    rect(s, 0, 0, 0.25, 7.5, ROSE)
    text(s, 0.6, 0.4, 12, 0.8, title, size=32, bold=True)
    if subtitle:
        text(s, 0.6, 1.1, 12, 0.5, subtitle, size=16, color=GREY)
    return s


def footer(s, n, src):
    text(s, 0.6, 7.0, 10.5, 0.35, src, size=11, color=GREY)
    text(s, 12.0, 7.0, 0.8, 0.35, str(n), size=11, color=GREY, align=PP_ALIGN.RIGHT)


def card(s, x, y, w, h, head, body_items, head_fill=NAVY, size=15):
    rect(s, x, y, w, h, LIGHT)
    rect(s, x, y, w, 0.6, head_fill)
    text(s, x + 0.1, y, w - 0.2, 0.6, head, size=18, bold=True, color=WHITE,
         anchor=MSO_ANCHOR.MIDDLE)
    bullets(s, x + 0.15, y + 0.75, w - 0.3, h - 0.85, body_items, size=size, gap=5)


def stat(s, x, y, w, big, small, fill=ROSE):
    rect(s, x, y, w, 1.9, fill)
    text(s, x, y + 0.1, w, 0.9, big, size=40, bold=True, color=WHITE, align=PP_ALIGN.CENTER,
         anchor=MSO_ANCHOR.MIDDLE)
    text(s, x + 0.15, y + 1.0, w - 0.3, 0.85, small, size=14, color=WHITE,
         align=PP_ALIGN.CENTER)


# 1 Title
s = prs.slides.add_slide(BLANK)
s.background.fill.solid()
s.background.fill.fore_color.rgb = NAVY
rect(s, 0.8, 2.3, 0.12, 2.2, ROSE)
text(s, 1.2, 2.2, 11, 1.2, "Peripartum Cardiomyopathy", size=50, bold=True, color=WHITE)
text(s, 1.2, 3.4, 11, 0.8, "Pathophysiology, diagnosis, management and prognosis", size=24,
     color=RGBColor(0xE8, 0xC4, 0xCD))
text(s, 1.2, 4.2, 11, 0.5, "Based on Harrison's 22E, Goldman-Cecil, Creasy & Resnik's, Braunwald and Fuster",
     size=14, color=RGBColor(0xB8, 0xC0, 0xCF))

# 2 Definition
s = content_slide("What is peripartum cardiomyopathy?")
rect(s, 0.6, 1.5, 12.1, 1.5, SOFT)
text(s, 0.85, 1.55, 11.6, 1.4,
     "Heart failure from left ventricular systolic dysfunction that develops in the last month "
     "of pregnancy or within 5 months after delivery, with no other identifiable cause.",
     size=22, bold=True, anchor=MSO_ANCHOR.MIDDLE)
bullets(s, 0.6, 3.3, 6.0, 3.5, [
    ("Timing:", "most cases present in the first week or two after delivery"),
    ("LVEF:", "usually below 45% (some definitions use 45% or less)"),
    ("Type:", "a dilated cardiomyopathy phenotype with a diagnosis of exclusion"),
], size=18)
rect(s, 7.0, 3.3, 5.7, 3.2, NAVY)
text(s, 7.2, 3.4, 5.3, 0.5, "Why it matters", size=20, bold=True, color=WHITE)
bullets(s, 7.2, 4.0, 5.3, 2.5, [
    "Cardiovascular conditions cause over 33% of pregnancy-related deaths in the US",
    "Easy to miss: late-pregnancy dyspnea and edema look normal",
    "Can recur in later pregnancies",
], size=16, color=WHITE)
footer(s, 2, "Harrison's 22E, p. 2060; Goldman-Cecil Medicine, p. 2587")

# 3 Epidemiology
s = content_slide("Epidemiology and risk factors")
stat(s, 0.6, 1.5, 3.8, "~1 in 1000", "pregnancies worldwide; varies by region")
stat(s, 4.75, 1.5, 3.8, "1 in 2230", "US births now, up from 1 in 4350 in the early 1990s", fill=NAVY)
stat(s, 8.9, 1.5, 3.8, "up to 1 in 100", "in parts of Africa (about 1 in 300 in Haiti)")
text(s, 0.6, 3.65, 6, 0.5, "Risk factors", size=22, bold=True, color=ROSE)
bullets(s, 0.6, 4.15, 6.0, 2.8, [
    "Older maternal age and higher parity",
    "Twin or multifetal pregnancy",
    "Malnutrition and obesity",
    "Tocolytic therapy and fertility treatment",
], size=17)
bullets(s, 6.9, 4.15, 5.8, 2.8, [
    ("Hypertensive disorders:", "up to half of cases; preeclampsia in about 25% vs 5% in the general population"),
    ("Ethnicity:", "Black women have a 4- to 15-fold higher risk and recover less often"),
], size=17)
footer(s, 3, "Harrison's 22E, p. 2060; Goldman-Cecil, p. 2587; Creasy & Resnik's, p. 1262")

# 4 Pathophysiology
s = content_slide("Pathophysiology: a multi-hit model",
                  "Pregnancy triggers cardiac injury in genetically or vascularly susceptible women")
card(s, 0.6, 1.8, 3.9, 4.9, "1. Genetic susceptibility", [
    "Truncating variants in about 15% of cases",
    "Mostly TTN (titin); also TNNC1 and STAT3",
    "Predicts lower LVEF recovery",
    "Pregnancy acts as a trigger on an underlying genetic dilated cardiomyopathy",
])
card(s, 4.72, 1.8, 3.9, 4.9, "2. Prolactin cleavage", [
    "Oxidative stress in late pregnancy",
    "Prolactin is cleaved to a 16-kDa fragment (vasoinhibin)",
    "Fragment is vasotoxic and proinflammatory",
    "Impairs endothelial cells and cardiomyocytes",
], head_fill=ROSE)
card(s, 8.84, 1.8, 3.9, 4.9, "3. Angiogenic imbalance", [
    "Placenta releases sFlt-1, an inhibitor of VEGF",
    "Shared with preeclampsia",
    "High sFlt-1 levels predict a worse outcome",
])
footer(s, 4, "Harrison's 22E, p. 2060; Goldman-Cecil, p. 2588; Creasy & Resnik's, p. 1262")

# 5 Presentation
s = content_slide("Clinical presentation")
card(s, 0.6, 1.5, 6.0, 5.2, "Symptoms and signs", [
    "Dyspnea, orthopnea, fatigue and cough",
    "Peripheral edema, raised JVP, hypertension",
    "Often appears when urine output lags behind postpartum fluid mobilisation",
    "Atrial and ventricular arrhythmias",
    "Thromboembolism, including LV thrombus",
], size=17)
card(s, 6.9, 1.5, 5.8, 5.2, "Clues that it is not normal pregnancy", [
    "Elevated BNP or NT-proBNP",
    "Elevated troponin",
    "Raised central venous pressure",
    "Dyspnea out of proportion, especially with hypertension",
    "Symptoms that start late in pregnancy or postpartum",
], head_fill=ROSE, size=17)
footer(s, 5, "Harrison's 22E, p. 2060-2061; Goldman-Cecil, p. 2588")

# 6 Diagnosis
s = content_slide("Diagnosis: a diagnosis of exclusion")
card(s, 0.6, 1.5, 5.9, 3.0, "Echocardiographic criteria", [
    "Diffuse systolic dysfunction",
    "LVEF below 45%",
    "Fractional shortening below 30%, or LVEDD above 2.7 cm/m\u00b2",
], size=16)
card(s, 0.6, 4.7, 5.9, 2.15, "Other tests", [
    "ECG, BNP, troponin, chest X-ray",
    "Cardiac MRI in complex cases, without gadolinium in pregnancy",
    "Consider genetic testing",
], head_fill=ROSE, size=15)
card(s, 6.8, 1.5, 5.9, 5.35, "Exclude other causes", [
    "Pulmonary embolism",
    "Coronary artery dissection (segmental wall motion abnormality)",
    "Valvular or pericardial disease",
    "Preexisting or familial cardiomyopathy",
    "Hypertensive heart disease and superimposed preeclampsia",
    "Sepsis",
    "Tocolytic beta-agonist effect (for example terbutaline)",
], size=16)
footer(s, 6, "Goldman-Cecil, p. 2588; Harrison's 22E, p. 2060-2061; Creasy & Resnik's, p. 1262")

# 7 Imaging
s = content_slide("Imaging findings")
s.shapes.add_picture("/tmp/workspace/ppcm-ppt/assets/img1.jpg", Inches(0.6), Inches(1.5),
                     height=Inches(3.9))
text(s, 0.6, 5.5, 5.0, 1.3,
     "Echocardiography, apical four-chamber view: dilated, globular left ventricle with "
     "global hypokinesis and severe systolic dysfunction.", size=14, color=GREY)
s.shapes.add_picture("/tmp/workspace/ppcm-ppt/assets/img0.jpg", Inches(6.5), Inches(1.5),
                     width=Inches(6.2))
text(s, 6.5, 3.2, 6.2, 1.8,
     "Cardiac MRI: mildly dilated LV (cine four-chamber) with non-ischemic mid-wall late "
     "gadolinium enhancement in the basal inferolateral wall (arrows). Gadolinium is avoided "
     "during pregnancy.", size=14, color=GREY)
rect(s, 6.5, 5.1, 6.2, 1.6, SOFT)
text(s, 6.65, 5.15, 5.9, 1.5,
     "Echo is usually sufficient for diagnosis. MRI helps separate PPCM from myocarditis or "
     "ischemia and gives prognostic information on fibrosis.", size=15, anchor=MSO_ANCHOR.MIDDLE)
footer(s, 7, "Images: Orris medical image library (case figures from PMC sources)")

# 8 Management before delivery
s = content_slide("Management before delivery", "Standard heart failure care, adjusted for the fetus")
card(s, 0.6, 1.8, 6.0, 4.9, "Use", [
    ("Diuretics:", "loop diuretics to restore euvolemia"),
    ("Afterload:", "hydralazine plus nitrates"),
    ("Rate and rhythm:", "beta-blockers (metoprolol) and digoxin"),
    ("Delivery:", "prompt delivery after maternal stabilisation when diagnosed before birth"),
    ("Shock:", "inotropes, mechanical support, advanced HF centre"),
], size=16)
card(s, 6.9, 1.8, 5.8, 3.1, "Avoid in pregnancy", [
    "ACE inhibitors, ARBs and sacubitril/valsartan",
    "Mineralocorticoid antagonists",
    "Warfarin (use LMWH or UFH if anticoagulating)",
], head_fill=ROSE, size=16)
rect(s, 6.9, 5.1, 5.8, 1.6, SOFT)
text(s, 7.05, 5.15, 5.5, 1.5,
     "Involve maternal-fetal medicine, cardiology and anesthesia early, and plan for "
     "emergency delivery if the mother is unstable.", size=15, anchor=MSO_ANCHOR.MIDDLE)
footer(s, 8, "Harrison's 22E, p. 2061; Creasy & Resnik's, p. 1262-1263; Goldman-Cecil, p. 2588")

# 9 Postpartum management
s = content_slide("Management after delivery")
card(s, 0.6, 1.5, 4.0, 5.3, "Drug therapy", [
    "Full guideline-directed HF therapy once stable",
    "Enalapril, metoprolol and spironolactone are compatible with breastfeeding",
    "Titrate as for other forms of HFrEF",
], size=15)
card(s, 4.75, 1.5, 4.0, 5.3, "Anticoagulation", [
    "Consider when LVEF is below 35% or the LV is markedly dilated",
    "About 6 weeks once obstetric bleeding has resolved",
    "LMWH preferred in pregnancy; avoid warfarin then",
], head_fill=ROSE, size=15)
card(s, 8.9, 1.5, 3.8, 5.3, "Breastfeeding and devices", [
    "Breastfeeding is now generally encouraged if fluid balance is maintained",
    "Delay ICD placement, since many women recover",
    "Reassess LVEF after 3 to 6 months of optimal therapy",
], size=15)
footer(s, 9, "Harrison's 22E, p. 2061; Fuster and Hurst's The Heart 15e (chapter outline). ICD timing from clinical practice")

# 10 Bromocriptine
s = content_slide("Bromocriptine: promising but unproven")
rect(s, 0.6, 1.5, 6.0, 4.9, LIGHT)
text(s, 0.8, 1.6, 5.6, 0.5, "Rationale", size=22, bold=True, color=ROSE)
bullets(s, 0.8, 2.2, 5.6, 4.0, [
    "Dopamine agonist that blocks prolactin release",
    "Targets the 16-kDa prolactin fragment pathway",
    "Small studies showed LVEF improvement",
    "Larger trial data still awaited in the textbook sources",
], size=17)
rect(s, 6.9, 1.5, 5.8, 4.9, NAVY)
text(s, 7.1, 1.6, 5.4, 0.5, "In practice", size=22, bold=True, color=WHITE)
bullets(s, 7.1, 2.2, 5.4, 4.0, [
    "Use is described as controversial",
    "Goldman-Cecil lists 1.25 to 2.5 mg once daily if standard measures fail",
    "Prothrombotic risk, so give with anticoagulation",
    "Breastfeeding is stopped when it is used",
], size=17, color=WHITE)
text(s, 0.6, 6.5, 12, 0.4,
     "Check current ESC or AHA guidance before use; this deck did not review society guidelines.",
     size=14, color=GREY)
footer(s, 10, "Harrison's 22E, p. 2060-2061; Goldman-Cecil, p. 2588; Creasy & Resnik's, p. 1263")

# 11 Prognosis
s = content_slide("Prognosis and subsequent pregnancy")
stat(s, 0.6, 1.5, 3.8, "50-80%", "recover LVEF to 50% or higher, mostly in 6 to 12 months", fill=NAVY)
stat(s, 4.75, 1.5, 3.8, "~20%", "recurrent heart failure in a later pregnancy if LVEF had normalised")
stat(s, 8.9, 1.5, 3.8, "~40%", "recurrence if LV dysfunction persisted; 19% maternal mortality in that study")
card(s, 0.6, 3.75, 6.0, 3.0, "Poorer recovery with", [
    "Lower LVEF or marked LV dilation at diagnosis",
    "Black race",
    "Truncating TTN variants",
], head_fill=ROSE, size=16)
card(s, 6.9, 3.75, 5.8, 3.0, "Counselling", [
    "Advise against pregnancy with persistent LV dysfunction",
    "Recovered women still need preconception review and close monitoring",
], size=16)
footer(s, 11, "Harrison's 22E, p. 2061; Creasy & Resnik's, p. 1262")

# 12 Recent evidence
s = content_slide("Recent evidence")
text(s, 0.6, 1.4, 12, 0.5, "Systematic reviews from the last 2 years (titles reviewed, abstracts not read)",
     size=16, color=GREY)
items = [
    ("2026", "Respiratory-onset PPCM: diagnostic pitfalls and outcomes", "PMID 42219619"),
    ("2025", "Risk factors for PPCM: systematic review and meta-analysis", "PMID 40701904"),
    ("2024", "Outcomes of subsequent pregnancy in PPCM: systematic review and meta-analysis", "PMID 38569669"),
]
y = 2.1
for yr, t, pm in items:
    rect(s, 0.6, y, 12.1, 1.15, LIGHT)
    rect(s, 0.6, y, 1.4, 1.15, ROSE)
    text(s, 0.6, y, 1.4, 1.15, yr, size=24, bold=True, color=WHITE, align=PP_ALIGN.CENTER,
         anchor=MSO_ANCHOR.MIDDLE)
    text(s, 2.2, y, 8.0, 1.15, t, size=17, anchor=MSO_ANCHOR.MIDDLE)
    text(s, 10.3, y, 2.3, 1.15, pm, size=14, color=GREY, anchor=MSO_ANCHOR.MIDDLE)
    y += 1.35
text(s, 0.6, 6.2, 12, 0.6,
     "None appears to overturn the textbook account. Delayed diagnosis remains a recurring problem.",
     size=16, bold=True)
footer(s, 12, "PubMed search, November 2026")

# 13 Take-home
s = prs.slides.add_slide(BLANK)
s.background.fill.solid()
s.background.fill.fore_color.rgb = NAVY
text(s, 0.8, 0.6, 12, 0.9, "Key takeaways", size=36, bold=True, color=WHITE)
rect(s, 0.8, 1.5, 1.2, 0.07, ROSE)
bullets(s, 0.8, 1.9, 11.7, 5, [
    "Think of PPCM in any woman with new dyspnea or edema in late pregnancy or the first months postpartum.",
    "Diagnosis needs LVEF below 45% and exclusion of other causes; BNP and echo are the first steps.",
    "Before delivery use diuretics, hydralazine-nitrates and beta-blockers; avoid ACEi, ARB, ARNI and MRA.",
    "After delivery give full heart failure therapy; consider anticoagulation if LVEF is below 35%.",
    "Bromocriptine remains controversial; delay ICD placement and reassess LVEF at 3 to 6 months.",
    "Most women recover, but later pregnancy carries a real risk of relapse. Counsel early.",
], size=20, color=WHITE, gap=12)

prs.save("/tmp/workspace/ppcm-ppt/output/Peripartum_Cardiomyopathy.pptx")
print("saved")