const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Medical Education";
pres.title = "Ectopic Pregnancy – Final Year MBBS";

// ─── COLOR PALETTE ───────────────────────────────────────────────
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  goldLt:  "F5C96A",   // light gold
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// ─── SHARED HELPERS ──────────────────────────────────────────────
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  slide.addText("Ectopic Pregnancy  |  Final Year MBBS  |  Ref: Berek & Novak's Gynecology", {
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// ════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

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  s.addText("ECTOPIC PREGNANCY", {
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  s.addText("A Comprehensive Review for Final Year MBBS", {
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    { text: "Berek & Novak's Gynecology (16th Ed.) + Tintinalli's Emergency Medicine", options: { bold: false, color: C.ltGray, fontSize: 12, fontFace: "Calibri" } },
  ], { x: 0.35, y: 2.2, w: 9.3, h: 0.4 });

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  s.addText("LEARNING OBJECTIVES", {
    x: 0.45, y: 2.78, w: 9.1, h: 0.32,
    fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri", charSpacing: 2,
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  s.addText([
    { text: "1.  Define ectopic pregnancy and describe its classification and epidemiology", options: { bullet: false, fontSize: 11.5, color: C.white, fontFace: "Calibri", breakLine: true } },
    { text: "2.  Identify risk factors and explain the pathophysiology", options: { bullet: false, fontSize: 11.5, color: C.white, fontFace: "Calibri", breakLine: true } },
    { text: "3.  Recognise the clinical features and diagnostic workup (β-hCG + TVS algorithm)", options: { bullet: false, fontSize: 11.5, color: C.white, fontFace: "Calibri", breakLine: true } },
    { text: "4.  Compare expectant, medical (methotrexate), and surgical management", options: { bullet: false, fontSize: 11.5, color: C.white, fontFace: "Calibri", breakLine: true } },
    { text: "5.  Discuss complications, prognosis, and future fertility", options: { bullet: false, fontSize: 11.5, color: C.white, fontFace: "Calibri" } },
  ], { x: 0.5, y: 3.12, w: 9.0, h: 1.75, valign: "top", paraSpaceAfter: 3 });

  s.addNotes("Welcome slide. Introduce ectopic pregnancy as a life-threatening obstetric emergency that accounts for ~2.7% of all maternal deaths. Emphasise that early diagnosis has dramatically improved outcomes. Outline the 5 learning objectives and inform students this topic is high-yield for MBBS finals and clinical OSCEs.");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 2 – DEFINITION, EPIDEMIOLOGY & CLASSIFICATION
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(s, "Definition, Epidemiology & Classification", "Slide 2 of 11");

  // Definition box
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    { text: "DEFINITION: ", options: { bold:true, fontSize:13, color:C.gold, fontFace:"Calibri" } },
    { text: "Implantation of a fertilised ovum outside the normal uterine cavity.", options: { bold:false, fontSize:13, color:C.white, fontFace:"Calibri" } },
  ], { x:0.4, y:0.97, w:9.2, h:0.62, valign:"middle", margin:0 });

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  // Left column
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    "Incidence: 1–2% of all pregnancies",
    "16% of women with 1st-trimester pain/bleeding have ectopic",
    "Accounts for ~2.7% of maternal deaths",
    "Leading cause of maternal death in 1st trimester",
    "African American women: 6.8x higher mortality",
    "Incidence increases with age (peaks 25–34 yrs)",
  ], C.teal);

  // Right column – Classification table
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  });

  const classRows = [
    ["Site", "Frequency", ""],
    ["Fallopian tube", "~96–98%", "★ Most common"],
    ["  - Ampullary", "70%", "★ Most common site"],
    ["  - Isthmic", "12%", "Ruptures earlier"],
    ["  - Fimbrial", "11%", ""],
    ["  - Interstitial", "2–3%", "Most dangerous"],
    ["Ovarian", "0.5%", ""],
    ["Abdominal", "1.3%", "Secondary/primary"],
    ["Cervical", "< 1%", "Torrential bleed"],
    ["Heterotopic", "1:4000", "IVF: 1:100"],
  ];

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  });

  examPearl(s, 0.3, 4.88, 9.4, "Ampullary is the most common site; interstitial has the highest mortality due to late presentation and catastrophic haemorrhage.");

  s.addNotes("Key teaching points:\n• Ectopic = implantation OUTSIDE normal uterine cavity\n• ~96-98% occur in fallopian tubes — ampullary region most common (70%)\n• Interstitial/cornual ectopics present late (10-14 weeks), rupture is catastrophic\n• Heterotopic pregnancy (simultaneous IUC + ectopic) is rare but more common after IVF (1:100)\n• Mortality has declined due to early TVS + bhCG diagnosis");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 3 – RISK FACTORS & PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(s, "Risk Factors & Pathophysiology", "Slide 3 of 11");

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    "MAJOR (RR > 4):",
    "Prior ectopic (recurrence 10-15%; 30% after 2nd)",
    "Tubal surgery / salpingotomy",
    "In-vitro fertilisation (IVF) / ART",
    "Documented tubal pathology",
    "MODERATE (RR 2–4):",
    "Pelvic inflammatory disease (PID)",
    "Prior pelvic / abdominal surgery",
    "Infertility (unexplained)",
    "MINOR (RR 1.1–2):",
    "Smoking, multiple sexual partners",
    "IUD in situ (if pregnancy occurs)",
    "Early age at first intercourse",
  ], C.red);

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    { t: "Tubal damage / impaired motility", c: C.teal },
    { t: "Delayed embryo transport (Day 6-8)", c: C.teal },
    { t: "Implantation in tubal mucosa", c: C.darkGray },
    { t: "Trophoblast invades tubal wall", c: C.darkGray },
    { t: "Tubal distension", c: C.red },
    { t: "Rupture → Haemoperitoneum", c: C.red },
  ];
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  examPearl(s, 0.3, 4.28, 9.4, "Up to 50% of ectopic pregnancies have NO identifiable risk factor — always consider ectopic in any woman of reproductive age with pain + positive UPT.");

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  s.addNotes("Risk factors: emphasise that prior ectopic is the single strongest risk factor (10-15% recurrence, 30% after second). PID caused by Chlamydia trachomatis is the leading preventable cause.\n\nPathophysiology: fertilisation occurs in ampulla. Normally embryo transported by ciliary action + peristalsis to uterus by day 4-5. If transport is delayed (tubal damage, motility dysfunction), implantation occurs in tube. Trophoblast invades thin tubal wall → distension → rupture usually at 6-8 weeks (ampullary), but interstitial can last to 12-14 weeks.");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 4 – CLINICAL FEATURES & PHYSICAL EXAMINATION
// ════════════════════════════════════════════════════════════════
{
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  addSlideHeader(s, "Clinical Features & Physical Examination", "Slide 4 of 11");

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    { text:"CLASSIC TRIAD: ", options:{bold:true,fontSize:13,color:C.navy,fontFace:"Calibri"} },
    { text:"Amenorrhoea  +  Lower abdominal pain  +  Vaginal bleeding  (only in ~50% of cases — absence does NOT exclude ectopic)", options:{bold:false,fontSize:12,color:C.darkGray,fontFace:"Calibri"} },
  ], {x:0.4,y:0.92,w:9.2,h:0.46,valign:"middle",margin:0});

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    "Amenorrhoea (6–8 weeks in tubal)",
    "Unilateral lower abdominal pain (dull/colicky)",
    "Irregular per-vaginal bleeding (dark, scanty)",
    "Nausea, vomiting (HCG effect)",
    "Shoulder tip pain (early sub-diaphragmatic blood)",
    "Urinary symptoms (pressure effect)",
    "Adnexal tenderness on PV exam",
    "Cervical excitation (pathognomonic of pelvic peritonitis)",
    "Adnexal mass palpable in ~50%",
  ], C.tealLt);

  calloutBox(s, 5.0, 1.55, 4.7, 2.55, "RUPTURED (Acute Emergency)", [
    "Sudden severe lower abdominal pain",
    "Haemoperitoneum → peritonism",
    "Shoulder-tip pain (blood under diaphragm)",
    "Pallor, sweating, cold clammy skin",
    "Tachycardia, hypotension, syncope",
    "Abdominal guarding and rigidity",
    "Cervical excitation +++",
    "Bulging Douglas pouch (culdocentesis: non-clotting blood)",
    "Signs of shock — SURGICAL EMERGENCY",
  ], C.red);

  // Exam note box
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    x:0.3, y:4.2, w:9.4, h:0.65,
    fill:{color:"FFF3CD"}, line:{color:C.gold, pt:1.5},
  });
  s.addText([
    {text:"PV EXAM FINDINGS: ", options:{bold:true,fontSize:11,color:C.red,fontFace:"Calibri"}},
    {text:"Cervical motion tenderness (CMT) / excitation is highly suggestive of pelvic peritonitis. Closed os with softened cervix (Goodell's sign). Adnexal mass separate from ovary in 50% cases. Blue-tinged cervix (Chadwick's sign) may be seen.", options:{bold:false,fontSize:10.5,color:C.darkGray,fontFace:"Calibri"}},
  ], {x:0.4,y:4.23,w:9.2,h:0.58,valign:"middle",margin:0});

  s.addNotes("Teaching points:\n• Classic triad present in only ~50% — high clinical suspicion mandatory\n• Any sexually active woman of reproductive age with abdominal pain must have a pregnancy test\n• Shoulder-tip pain (Kehr's sign) = diaphragmatic irritation by blood — sign of rupture\n• CMT (cervical motion tenderness) = pelvic peritonitis, not specific for ectopic but important sign\n• Ruptured ectopic = life-threatening → stabilise and call OT\n• Syncope in early pregnancy = ectopic until proven otherwise");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 5 – DIAGNOSIS
// ════════════════════════════════════════════════════════════════
{
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  addSlideHeader(s, "Diagnosis: β-hCG, Ultrasound & Investigations", "Slide 5 of 11");

  // β-hCG box
  calloutBox(s, 0.3, 0.92, 4.55, 2.05, "β-hCG (Serum Quantitative)", [
    "Discriminatory zone: 1500–2000 mIU/mL",
    "Normal IUP: doubles every 48h (>66% rise)",
    "Ectopic / abnormal: rise <66% or plateau/fall",
    "β-hCG >2000 + no IUP on TVS = ectopic until proven otherwise",
    "Single value cannot diagnose ectopic — serial monitoring required",
    "Falling bhCG does NOT mean safe to discharge",
  ], C.teal);

  // TVS findings
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    "First-line imaging modality",
    "Gestational sac seen at bhCG ~1500 mIU/mL",
    "Findings: empty uterus + adnexal mass",
    "\"Tubal ring\" sign: echogenic ring around sac",
    "Fetal cardiac activity outside uterus (diagnostic)",
    "Free fluid in POD (haemoperitoneum)",
    "Pseudosac: decidual reaction in endometrium (not true GS)",
  ], C.navy);

  // Diagnostic Algorithm (flowchart)
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    x:0.3, y:3.05, w:9.4, h:0.28,
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  });

  // Flowchart nodes
  const nodes = [
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    { x:2.8,  y:3.38, w:2.0, h:0.38, t:"Serum β-hCG\n(quantitative)", c:C.teal },
    { x:5.1,  y:3.38, w:2.1, h:0.38, t:"TVS\n(transvaginal USS)", c:C.teal },
    { x:7.5,  y:3.38, w:2.2, h:0.38, t:"IUP confirmed\n→ Routine ANC", c:C.green },
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  });
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  ["→","→","→"].forEach((a,i)=>{
    s.addText(a, { x:2.52+i*2.3, y:3.44, w:0.28, h:0.26, fontSize:14, color:C.midGray, fontFace:"Calibri", align:"center" });
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    x:5.1, y:3.9, w:2.1, h:0.35,
    fill:{color:C.red}, line:{color:C.red}, rectRadius:0.05,
  });
  s.addText("Adnexal mass / empty uterus\n→ ECTOPIC (manage)", { x:5.15, y:3.92, w:2.0, h:0.31, fontSize:8, color:C.white, fontFace:"Calibri", valign:"middle", align:"center", margin:0 });
  s.addText("↓", { x:5.95, y:3.78, w:0.4, h:0.14, fontSize:11, color:C.midGray, fontFace:"Calibri", align:"center" });

  s.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x:2.8, y:3.9, w:2.0, h:0.35,
    fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.05,
  });
  s.addText("bhCG <1500 + no IUP\n→ PUL (serial bhCG + USS)", { x:2.85, y:3.92, w:1.9, h:0.31, fontSize:8, color:C.navy, fontFace:"Calibri", valign:"middle", align:"center", margin:0 });
  s.addText("↓", { x:3.65, y:3.78, w:0.4, h:0.14, fontSize:11, color:C.midGray, fontFace:"Calibri", align:"center" });

  // Other investigations
  s.addText([
    {text:"OTHER INVESTIGATIONS: ", options:{bold:true,fontSize:10,color:C.navy,fontFace:"Calibri"}},
    {text:"FBC (Hb, haematocrit) | Blood group & cross-match | Coagulation screen | Culdocentesis (non-clotting blood = haemoperitoneum) | Diagnostic laparoscopy (gold standard if USS inconclusive)", options:{bold:false,fontSize:9.5,color:C.darkGray,fontFace:"Calibri"}},
  ], { x:0.3, y:4.33, w:9.4, h:0.5, valign:"middle",
    fill:{color:"E8F4F8"}, margin:5,
  });

  examPearl(s, 0.3, 4.88, 9.4, "PUL = Pregnancy of Unknown Location. All PULs need serial bhCG + TVS. Diagnostic laparoscopy = gold standard for definitive diagnosis.");

  s.addNotes("Discriminatory zone = bhCG level above which an IUP should be visible on TVS (1500-2000 mIU/mL TVS; 6500 mIU/mL transabdominal).\n\nKey points:\n• Pseudosac (decidual cast) can mimic gestational sac — true GS has double decidual sign\n• 'Tubal ring' or 'bagel sign' = echogenic ring around extrauterine sac\n• bhCG can be low in ectopic — a low/negative value does NOT fully exclude\n• Laparoscopy = gold standard but invasive; TVS + bhCG trend have largely replaced it for diagnosis");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 6 – DIFFERENTIAL DIAGNOSIS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.offWhite}, line:{color:C.offWhite} });
  addSlideHeader(s, "Differential Diagnosis", "Slide 6 of 11");

  // Table
  s.addShape(pres.shapes.RECTANGLE, { x:0.3, y:0.92, w:9.4, h:0.3, fill:{color:C.navy}, line:{color:C.navy} });
  ["Condition","Pregnancy Test","Pain","Bleeding","Key Feature"].forEach((h,i)=>{
    const xPositions = [0.32, 2.4, 4.1, 5.6, 7.1];
    const widths = [2.05, 1.65, 1.45, 1.45, 2.6];
    s.addText(h, { x:xPositions[i], y:0.94, w:widths[i], h:0.26, fontSize:9.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:3 });
  });

  const ddxRows = [
    ["Ectopic Pregnancy",     "+ve",  "Unilateral",  "Scanty dark",  "Adnexal mass, CMT"],
    ["Miscarriage (threatened)","+ ve","Bilateral cramps","Red, heavy","Open/closed os; IUP on USS"],
    ["Corpus luteum cyst",    "+ve or -ve","Unilateral","Nil/minimal", "Cystic adnexal mass, IUP seen"],
    ["PID",                   "-ve",  "Bilateral",   "Nil/discharge","Fever, vaginal discharge, CMT"],
    ["Appendicitis",          "-ve",  "RIF, migrating","Nil",          "Nausea/vomiting, Rovsing's sign"],
    ["Ovarian torsion",       "+/-",  "Severe, sudden","Nil",          "Doppler: absent flow; nausea"],
    ["Urinary tract infection","-ve", "Supra-pubic",  "Nil",          "Dysuria, frequency, pyuria"],
    ["Degenerating fibroid",  "+/-",  "Localised",   "Heavy PV",     "Uterine mass on USS"],
    ["Ovarian hyperstimulation","+ ve","Bilateral",  "Nil",           "Post-IVF, enlarged ovaries"],
  ];

  ddxRows.forEach((row, i) => {
    const bg = i % 2 === 0 ? C.white : "EEF2F7";
    const isFirst = row[0] === "Ectopic Pregnancy";
    s.addShape(pres.shapes.RECTANGLE, {
      x:0.3, y:1.22+i*0.38, w:9.4, h:0.38,
      fill:{color: isFirst ? "FFF3CD" : bg}, line:{color:C.ltGray, pt:0.5},
    });
    const xPositions = [0.32, 2.4, 4.1, 5.6, 7.1];
    const widths = [2.05, 1.65, 1.45, 1.45, 2.6];
    row.forEach((cell, ci) => {
      s.addText(cell, {
        x:xPositions[ci], y:1.24+i*0.38, w:widths[ci], h:0.34,
        fontSize: isFirst ? 9.5 : 9, bold: isFirst, 
        color: isFirst ? C.navy : (ci===0 ? C.darkGray : C.midGray),
        fontFace:"Calibri", valign:"middle", margin:3,
      });
    });
  });

  examPearl(s, 0.3, 4.88, 9.4, "Key differentiator: ectopic has POSITIVE pregnancy test + adnexal mass + empty uterus on TVS. PID is the most common misdiagnosis — check HCG first.");

  s.addNotes("Differential diagnosis is critical because ectopic can mimic many conditions.\nImportant exam points:\n• Always do a urine/serum pregnancy test FIRST in any woman of reproductive age with abdominal pain\n• PID most commonly confused with ectopic — but PID has -ve pregnancy test + bilateral symptoms + fever\n• Corpus luteum cyst: +ve UPT but IUP seen on USS; corpus luteum on contralateral side\n• Heterotopic: both IUP + ectopic — rare but must keep in mind in IVF patients\n• Surgical abdomen (appendicitis, torsion) must be rapidly distinguished — USS is key");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 7 – MANAGEMENT
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.offWhite}, line:{color:C.offWhite} });
  addSlideHeader(s, "Management: Expectant, Medical & Surgical", "Slide 7 of 11");

  // Three management boxes
  // 1. Expectant
  calloutBox(s, 0.2, 0.95, 3.05, 3.3, "EXPECTANT", [
    "Indications:",
    "Declining bhCG (<1000) on serial testing",
    "Minimal symptoms, clinically stable",
    "Adnexal mass <3cm, no FCA",
    "Patient reliable for follow-up",
    "Protocol:",
    "Serial bhCG every 48h → weekly",
    "Repeat TVS at 1–2 weeks",
    "Admit if pain worsens",
    "Success rate: 50–70% (spontaneous resolution)",
    "Contraindications:",
    "Rising bhCG, rupture, haemodynamic instability",
  ], C.green);

  // 2. Medical (MTX)
  calloutBox(s, 3.45, 0.95, 3.1, 3.3, "MEDICAL — METHOTREXATE", [
    "Mechanism: Folic acid antagonist → inhibits trophoblast proliferation",
    "Indications (all must be met):",
    "Haemodynamic stability",
    "bhCG <5000 mIU/mL (single dose)",
    "No FCA on TVS",
    "Mass <3.5–4 cm",
    "No contraindication to MTX",
    "Dose: Single IM 50 mg/m² BSA",
    "Follow-up: bhCG on day 4 & 7",
    "Success: >15% fall day 4→7 = success",
    "Contraindications:",
    "Renal/hepatic disease, immunosuppression",
    "Breastfeeding, haemodynamic instability",
  ], C.teal);

  // 3. Surgical
  calloutBox(s, 6.7, 0.95, 3.1, 3.3, "SURGICAL", [
    "Laparoscopy (preferred):",
    "Haemodynamically stable",
    "Failed medical Rx",
    "Contraindication to MTX",
    "Salpingectomy vs salpingostomy",
    "Laparotomy:",
    "Haemodynamic instability / rupture",
    "Large haemoperitoneum",
    "Inaccessible location",
    "Procedures:",
    "Salpingectomy: tube removal (↑ recurrence vs salpingostomy — DISPUTED)",
    "Salpingostomy: incise tube, remove ectopic, leave tube",
    "Interstitial: cornual resection",
  ], C.red);

  // MTX follow-up protocol box
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:4.35, w:9.6, h:0.55,
    fill:{color:"E8F4F8"}, line:{color:C.teal, pt:1.5},
  });
  s.addText([
    {text:"MTX FOLLOW-UP PROTOCOL: ", options:{bold:true,fontSize:10,color:C.teal,fontFace:"Calibri"}},
    {text:"Day 1 (injection) → Day 4 bhCG → Day 7 bhCG. If fall <15% between Day 4–7 → 2nd dose. Continue weekly bhCG until undetectable (<5 mIU/mL). Avoid sexual intercourse, NSAIDs, folic acid, sunlight, alcohol during treatment.", options:{bold:false,fontSize:9.5,color:C.darkGray,fontFace:"Calibri"}},
  ], {x:0.3, y:4.38, w:9.4, h:0.48, valign:"middle", margin:0});

  examPearl(s, 0.2, 4.95, 9.6, "Day 4–7 bhCG fall >15% = MTX success. Laparoscopy > laparotomy (shorter stay, less adhesions, quicker recovery). Salpingectomy preferred if contralateral tube healthy.");

  s.addNotes("Management overview:\n1. Expectant: watchful waiting for declining bhCG; 50-70% resolve spontaneously; requires reliable patient compliance\n2. Methotrexate (MTX): single IM dose 50mg/m2 BSA. Key: bhCG <5000, no FCA, mass <3.5cm, stable. Monitor Day 1,4,7. >15% fall D4→D7 = success. Second dose if insufficient fall.\n3. Surgical: laparoscopy preferred over laparotomy. Salpingectomy removes the tube (preferred if other tube normal). Salpingostomy conserves tube (useful if contralateral tube damaged).\nRupture = immediate laparotomy/laparoscopy. Resuscitate with IV fluids + cross-matched blood.");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 8 – COMPLICATIONS, PROGNOSIS & FUTURE FERTILITY
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.offWhite}, line:{color:C.offWhite} });
  addSlideHeader(s, "Complications, Prognosis & Future Fertility", "Slide 8 of 11");

  calloutBox(s, 0.3, 0.95, 3.0, 2.6, "COMPLICATIONS", [
    "ACUTE:",
    "Tubal rupture (most feared)",
    "Haemoperitoneum / haemorrhagic shock",
    "Disseminated intravascular coagulation (DIC)",
    "Death (~2.7% maternal mortality)",
    "SUBACUTE / CHRONIC:",
    "Persistent ectopic (after salpingostomy)",
    "MTX toxicity: hepatitis, stomatitis, bone marrow suppression",
    "Intra-abdominal adhesions",
    "Secondary infertility",
  ], C.red);

  calloutBox(s, 3.5, 0.95, 3.0, 2.6, "PROGNOSIS & RECURRENCE", [
    "Mortality: <0.1% with early Rx (was 5% historically)",
    "Recurrence risk:",
    "After 1st ectopic: 10–15%",
    "After 2nd ectopic: ~30%",
    "IUP rate after ectopic: ~60%",
    "Live birth rate after MTX: ~60–70%",
    "Live birth rate after surgery: ~65–70%",
    "Persistent ectopic after salpingostomy: ~8–15%",
    "bhCG surveillance until <5 mIU/mL mandatory",
  ], C.navy);

  calloutBox(s, 6.7, 0.95, 3.0, 2.6, "FUTURE FERTILITY", [
    "Advise:  conceive after 3 months post-MTX",
    "Ensure adequate folic acid supplementation",
    "Early TVS in next pregnancy (at 6 weeks)",
    "HSG at 3 months post-MTX (optional)",
    "72% bilateral tubal patency after MTX",
    "After salpingectomy: similar IUP rates vs salpingostomy",
    "IVF recommended if contralateral tube damaged",
    "Psychological support: grief counselling important",
  ], C.tealLt);

  // Table: Comparison outcomes
  s.addShape(pres.shapes.RECTANGLE, { x:0.3, y:3.65, w:9.4, h:0.28, fill:{color:C.darkGray}, line:{color:C.darkGray} });
  ["Outcome", "Expectant", "Methotrexate", "Salpingostomy", "Salpingectomy"].forEach((h, i) => {
    const xs = [0.32, 2.15, 3.85, 5.6, 7.45];
    const ws = [1.8, 1.65, 1.7, 1.8, 2.2];
    s.addText(h, { x:xs[i], y:3.67, w:ws[i], h:0.24, fontSize:9, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:3 });
  });
  const outcomeRows = [
    ["Success rate", "50–70%", "70–95%", "95%+", "95%+"],
    ["Future IUP", "~65%", "60–70%", "65–70%", "65–70%"],
    ["Recurrence risk", "~15%", "~12%", "~15%", "~10%"],
    ["Tubal preservation", "Yes", "Yes", "Yes", "No"],
  ];
  outcomeRows.forEach((row, i) => {
    const bg = i % 2 === 0 ? C.white : "EEF2F7";
    s.addShape(pres.shapes.RECTANGLE, { x:0.3, y:3.93+i*0.23, w:9.4, h:0.23, fill:{color:bg}, line:{color:C.ltGray, pt:0.5} });
    const xs = [0.32, 2.15, 3.85, 5.6, 7.45];
    const ws = [1.8, 1.65, 1.7, 1.8, 2.2];
    row.forEach((cell, ci) => {
      s.addText(cell, { x:xs[ci], y:3.94+i*0.23, w:ws[ci], h:0.21, fontSize:8.5, color:ci===0?C.darkGray:C.midGray, fontFace:"Calibri", valign:"middle", margin:3, bold:ci===0 });
    });
  });

  examPearl(s, 0.3, 4.88, 9.4, "Persistent trophoblast: rising/plateauing bhCG after salpingostomy — treat with MTX. Advise 3 months contraception after MTX before attempting conception.");

  s.addNotes("Complications to emphasise:\n• Rupture can occur even with declining bhCG — always warn patient\n• Persistent ectopic (incomplete removal) — more common after salpingostomy — needs MTX\n• MTX toxicity at therapeutic doses is rare but monitor LFTs and FBC\n\nFuture fertility:\n• Both surgical and medical treatment have similar IUP rates (~65%)\n• Early TVS in ALL subsequent pregnancies to confirm intrauterine location\n• Salpingectomy does NOT significantly reduce fertility compared to salpingostomy (Cochrane review)");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 9 – EXAM PEARLS & TAKE-HOME MESSAGES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.navy}, line:{color:C.navy} });
  // Gold left bar
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:0.12, h:5.625, fill:{color:C.gold}, line:{color:C.gold} });
  addSlideHeader(s, "Key Take-Home Messages & Exam Pearls", "Slide 9 of 11");

  // Override footer for dark slide
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:5.42, w:10, h:0.2, fill:{color:"070F1E"}, line:{color:"070F1E"} });

  const pearls = [
    { n:"1", t:"Any pregnant woman + abdominal pain = ectopic until proven otherwise." },
    { n:"2", t:"Classic triad (amenorrhoea + pain + bleeding) present in only ~50% of cases." },
    { n:"3", t:"Ampullary = most common site (70%); interstitial = most dangerous (ruptures at 10–14 wks)." },
    { n:"4", t:"Discriminatory zone: β-hCG >1500–2000 mIU/mL → IUP must be visible on TVS." },
    { n:"5", t:"Serial β-hCG: normal IUP rises ≥66% in 48h; plateau or <66% rise = abnormal pregnancy." },
    { n:"6", t:"Methotrexate: Day 4→7 bhCG fall >15% = successful treatment. 50 mg/m² IM single dose." },
    { n:"7", t:"Laparoscopy > laparotomy (except rupture with instability: emergency laparotomy)." },
    { n:"8", t:"After 1st ectopic: 10–15% recurrence; after 2nd: ~30%. Earliest TVS in next pregnancy." },
    { n:"9", t:"PUL (Pregnancy of Unknown Location): bhCG + TVS inconclusive → serial monitoring." },
    { n:"10", t:"Avoid NSAIDs, folic acid, alcohol, sunlight during MTX treatment. Contraception 3 months post-MTX." },
  ];

  pearls.forEach((p, i) => {
    const col = i < 5 ? 0 : 1;
    const row = i % 5;
    const x = col === 0 ? 0.25 : 5.1;
    const y = 1.02 + row * 0.72;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, {
      x, y, w:4.65, h:0.62,
      fill:{color:"0A2040"}, line:{color:C.teal, pt:1}, rectRadius:0.06,
    });
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, {
      x:x+0.04, y:y+0.08, w:0.3, h:0.44,
      fill:{color:C.gold}, line:{color:C.gold}, rectRadius:0.04,
    });
    s.addText(p.n, { x:x+0.04, y:y+0.1, w:0.3, h:0.4, fontSize:11, bold:true, color:C.navy, fontFace:"Calibri", align:"center", valign:"middle", margin:0 });
    s.addText(p.t, { x:x+0.4, y:y+0.06, w:4.2, h:0.5, fontSize:9.5, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
  });

  s.addNotes("Rapid-fire revision slide. Ask students to cover the text and recall the pearl for each number. These 10 points cover the most frequently tested facts in MBBS theory papers and clinical OSCEs.\n\nHighlight in class:\n• Point 4 (discriminatory zone) and Point 6 (MTX follow-up) are most commonly tested numerically\n• Point 3 (site classification) frequently appears in single best answer questions\n• Point 8 (recurrence) and Point 2 (triad frequency) appear in short answer questions");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 10 – MCQs
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.offWhite}, line:{color:C.offWhite} });
  addSlideHeader(s, "Self-Assessment MCQs", "Slide 10 of 11");

  // MCQ 1 – Easy
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:0.9, w:9.5, h:0.26, fill:{color:C.teal}, line:{color:C.teal} });
  s.addText("MCQ 1 (Easy)  —  Most common site of ectopic pregnancy:", { x:0.3, y:0.92, w:9.4, h:0.22, fontSize:10.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
  s.addText([
    {text:"A. Isthmus of fallopian tube    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
    {text:"B. Ampulla of fallopian tube    ", options:{fontSize:10,color:C.green,bold:true,fontFace:"Calibri"}},
    {text:"C. Fimbrial end    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
    {text:"D. Interstitial portion", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
  ], { x:0.3, y:1.19, w:9.4, h:0.32, valign:"middle" });
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:1.52, w:9.5, h:0.26, fill:{color:"E8F8EF"}, line:{color:C.greenLt, pt:1} });
  s.addText("✔ Answer: B.  Ampulla (70% of all tubal ectopics). The ampullary region is the widest, most mobile segment — fertilisation occurs here and implantation follows if transport is impaired.", { x:0.3, y:1.54, w:9.3, h:0.22, fontSize:9, color:C.green, bold:false, fontFace:"Calibri", valign:"middle", margin:0 });

  // MCQ 2 – Moderate
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:1.88, w:9.5, h:0.26, fill:{color:C.tealLt}, line:{color:C.tealLt} });
  s.addText("MCQ 2 (Moderate)  —  A woman 7 weeks pregnant presents with bhCG 3200 mIU/mL and empty uterus on TVS. Serial bhCG at 48h shows only 30% rise. Next best step:", { x:0.3, y:1.9, w:9.4, h:0.22, fontSize:10.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
  s.addText([
    {text:"A. Repeat TVS in 1 week    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
    {text:"B. Administer methotrexate immediately    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
    {text:"C. Diagnostic laparoscopy    ", options:{fontSize:10,color:C.green,bold:true,fontFace:"Calibri"}},
    {text:"D. Serum progesterone level", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
  ], { x:0.3, y:2.17, w:9.4, h:0.32, valign:"middle" });
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:2.5, w:9.5, h:0.32, fill:{color:"E8F8EF"}, line:{color:C.greenLt, pt:1} });
  s.addText("✔ Answer: C.  bhCG >1500 + empty uterus on TVS = ectopic until proven otherwise. With bhCG 3200 (above discriminatory zone) and sub-optimal rise, laparoscopy is the most appropriate next step for definitive diagnosis and treatment. MTX requires confirmation of ectopic and full criteria assessment first.", { x:0.3, y:2.52, w:9.3, h:0.28, fontSize:9, color:C.green, fontFace:"Calibri", valign:"middle", margin:0 });

  // MCQ 3 – Difficult
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:2.9, w:9.5, h:0.26, fill:{color:C.red}, line:{color:C.red} });
  s.addText("MCQ 3 (Difficult/Clinical)  —  After salpingostomy for left-sided ectopic, bhCG on day 7 is higher than day 1. The most likely diagnosis and management:", { x:0.3, y:2.92, w:9.4, h:0.22, fontSize:10.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
  s.addText([
    {text:"A. Normal post-op bhCG rise — reassure and repeat in 2 weeks    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri",breakLine:true}},
    {text:"B. Heterotopic pregnancy — perform TVS    ", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri",breakLine:true}},
    {text:"C. Persistent ectopic trophoblast — administer systemic methotrexate    ", options:{fontSize:10,color:C.green,bold:true,fontFace:"Calibri",breakLine:true}},
    {text:"D. Re-implantation in contralateral tube — repeat laparoscopy", options:{fontSize:10,color:C.darkGray,fontFace:"Calibri"}},
  ], { x:0.3, y:3.2, w:9.4, h:0.62, valign:"top" });
  s.addShape(pres.shapes.RECTANGLE, { x:0.25, y:3.85, w:9.5, h:0.5, fill:{color:"E8F8EF"}, line:{color:C.greenLt, pt:1} });
  s.addText("✔ Answer: C.  Persistent ectopic trophoblast (viable trophoblast remaining after salpingostomy) occurs in 8–15% of cases. Rising or plateauing bhCG post-salpingostomy = persistent ectopic. Treatment: systemic MTX single dose 50 mg/m². Always monitor bhCG weekly after salpingostomy until undetectable.", { x:0.3, y:3.87, w:9.3, h:0.44, fontSize:9, color:C.green, fontFace:"Calibri", valign:"middle", margin:0 });

  examPearl(s, 0.25, 4.42, 9.5, "Salpingostomy ≠ complete treatment guarantee. Always monitor bhCG post-op. Rising bhCG = persistent trophoblast → methotrexate.");

  s.addNotes("MCQ notes for facilitator:\nMCQ1: Tests knowledge of anatomy/site classification. Distractor D (interstitial) is dangerous but least common.\nMCQ2: Tests the discriminatory zone concept and clinical decision-making. Key: bhCG >1500 + empty uterus + subnormal rise = high suspicion for ectopic. Laparoscopy is appropriate when bhCG is above discriminatory zone.\nMCQ3: Tests an important complication — persistent ectopic. This is a commonly missed exam concept. Salpingostomy preserves the tube but incomplete removal of trophoblast leads to persistent pregnancy. MTX is the treatment.");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 11 – REFERENCES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{color:C.navy}, line:{color:C.navy} });
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  addSlideHeader(s, "References", "Slide 11 of 11");
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  const refs = [
    {
      label: "PRIMARY REFERENCE",
      color: C.gold,
      items: [
        "1.  Berek JS, Novak E. Berek & Novak's Gynecology, 16th Edition. Wolters Kluwer; 2019. [Chapter: Ectopic Gestation, pp. 1752–1783]",
      ],
    },
    {
      label: "STANDARD TEXTBOOKS",
      color: C.teal,
      items: [
        "2.  Tintinalli JE et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Ed. McGraw-Hill; 2020. [Ectopic Pregnancy, pp. 744–762]",
        "3.  Creasy RK, Resnik R. Maternal-Fetal Medicine: Principles and Practice, 8th Ed. Elsevier; 2019.",
        "4.  Robbins SL, Kumar V. Robbins & Kumar Basic Pathology, 11th Ed. Elsevier; 2023.",
      ],
    },
    {
      label: "CLINICAL GUIDELINES",
      color: C.tealLt,
      items: [
        "5.  RCOG Green-top Guideline No. 21: The Management of Tubal Pregnancy. Royal College of Obstetricians and Gynaecologists; 2016.",
        "6.  ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. American College of Obstetricians and Gynecologists; 2018. Obstet Gynecol. 2018;131(3):e91–e103.",
        "7.  NICE Guideline NG126: Ectopic Pregnancy and Miscarriage. National Institute for Health and Care Excellence; 2021.",
      ],
    },
    {
      label: "NOTE",
      color: C.gold,
      items: [
        "Content is primarily based on Berek & Novak's Gynecology. RCOG/ACOG/NICE guidelines were referenced only for management protocols where consistent with the primary textbook. All epidemiological data are as cited in the referenced textbook editions.",
      ],
    },
  ];

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  s.addNotes("References slide. Emphasise to students that Berek & Novak is the primary evidence base for this presentation. RCOG/ACOG guidelines are consistent with textbook content and were used to supplement management protocols only. Students should refer to the most recent editions of these guidelines for clinical practice.");
}

// ════════════════════════════════════════════════════════════════
// WRITE FILE
// ════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/ectopic-pregnancy-ppt/Ectopic_Pregnancy_MBBS.pptx" })
  .then(() => console.log("SUCCESS: Ectopic_Pregnancy_MBBS.pptx created"))
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