mkdir -p /home/daytona/workspace/gynaecology-mcq && ls /home/daytona/workspace/g…

~/gynaecology-mcq/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY

doc = SimpleDocTemplate(
    "/home/daytona/workspace/gynaecology-mcq/Gynaecology_Obstetrics_MCQ_Answers.pdf",
    pagesize=A4,
    rightMargin=1.8*cm,
    leftMargin=1.8*cm,
    topMargin=2*cm,
    bottomMargin=2*cm
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    'CustomTitle',
    parent=styles['Title'],
    fontSize=16,
    spaceAfter=6,
    textColor=colors.HexColor('#1a1a6e'),
    alignment=TA_CENTER,
    fontName='Helvetica-Bold'
)

subtitle_style = ParagraphStyle(
    'SubTitle',
    parent=styles['Normal'],
    fontSize=10,
    spaceAfter=12,
    textColor=colors.HexColor('#555555'),
    alignment=TA_CENTER,
    fontName='Helvetica'
)

section_style = ParagraphStyle(
    'Section',
    parent=styles['Heading1'],
    fontSize=12,
    spaceBefore=14,
    spaceAfter=6,
    textColor=colors.white,
    backColor=colors.HexColor('#1a1a6e'),
    fontName='Helvetica-Bold',
    leftIndent=-5,
    rightIndent=-5,
    borderPadding=(4, 6, 4, 6),
)

q_style = ParagraphStyle(
    'Question',
    parent=styles['Normal'],
    fontSize=9.5,
    spaceBefore=8,
    spaceAfter=2,
    fontName='Helvetica-Bold',
    textColor=colors.HexColor('#1a1a6e'),
    leading=13
)

ans_style = ParagraphStyle(
    'Answer',
    parent=styles['Normal'],
    fontSize=9.5,
    spaceBefore=1,
    spaceAfter=1,
    fontName='Helvetica-Bold',
    textColor=colors.HexColor('#c00000'),
    leftIndent=10,
    leading=13
)

exp_style = ParagraphStyle(
    'Explanation',
    parent=styles['Normal'],
    fontSize=9,
    spaceBefore=2,
    spaceAfter=4,
    fontName='Helvetica',
    textColor=colors.HexColor('#333333'),
    leftIndent=10,
    leading=13,
    alignment=TA_JUSTIFY
)

note_style = ParagraphStyle(
    'Note',
    parent=styles['Normal'],
    fontSize=8.5,
    spaceBefore=2,
    spaceAfter=2,
    fontName='Helvetica-Oblique',
    textColor=colors.HexColor('#555555'),
    leftIndent=10,
    leading=12
)

story = []

# Title
story.append(Paragraph("GYNAECOLOGY & OBSTETRICS", title_style))
story.append(Paragraph("MCQ Answer Key with Explanations (Questions 1–100)", subtitle_style))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a1a6e'), spaceAfter=10))

# ─── DATA ───────────────────────────────────────────────────────────────────
data = [
    # (section_label, q_no, question, answer, explanation)

    # PAGE 1
    ("PAGE 1 (Q1–24)", None, None, None, None),
    (None, 1, "Anti D Immunoglobulin must be given to a mother of O negative group with baby of O positive within:", "D) 72 hours", "Anti-D (Rh) immunoglobulin must be given within 72 hours of delivery to an Rh-negative mother with an Rh-positive baby. This prevents alloimmunisation by neutralising fetal RBCs that entered maternal circulation. Prophylactic dose at 28 weeks is also given antenatally."),
    (None, 2, "Interstitial cell predominance on a vaginal cytology is seen in:", "C) Post ovulatory", "In the post-ovulatory (luteal) phase, progesterone predominates and causes intermediate/interstitial cells to dominate the vaginal smear. Estrogen (pre-ovulatory) produces superficial cells."),
    (None, 3, "Vaginal cytology for hormonal change are best taken from:", "C) Lateral wall", "The upper third of the lateral vaginal wall is the preferred site for hormonal cytology — free from cervical secretions, inflammatory cells, and endometrial contamination."),
    (None, 4, "The most unfavorable presentation is:", "B) Mentoposterior", "Mentoposterior (face presentation, chin posterior) is the most unfavorable because vaginal delivery is virtually impossible — the neck cannot extend further. Cesarean section is almost always required."),
    (None, 5, "Absolute contraindication for oral contraceptives are all EXCEPT:", "D) More than 30 years old", "Age >30 alone is NOT an absolute contraindication to OCPs. Absolute contraindications (WHO Category 4) include: heart disease with vascular involvement, uncontrolled hypertension, migraine with aura, and thromboembolic history."),
    (None, 6, "Post partum VVF is best repaired after:", "C) 3 months", "Post-partum fistulae are best repaired after 3 months to allow resolution of inflammatory oedema, improved tissue vascularisation, and maturation of the fistulous tract, greatly improving surgical success rates."),
    (None, 7, "Amount of amniotic fluid at 12 weeks is:", "A) 50 ml", "Amniotic fluid volume at 12 weeks is ~50 ml. It increases progressively: ~200 ml at 16 weeks, peaks at ~800–1000 ml at 36–38 weeks, then declines near term."),
    (None, 8, "Chromosome number of hydatidiform mole is:", "A) 46 XX", "A complete hydatidiform mole has a 46,XX karyotype — androgenetic diploid (both sets are paternal). A partial mole is typically 69,XXY (triploid). The 46,XX in a complete mole is entirely paternal in origin."),
    (None, 9, "Percentage of women who deliver on the expected date of delivery is:", "A) 4%", "Only ~4–5% of women deliver on their exact estimated due date (EDD). The majority deliver within 2 weeks before or after. The EDD is a statistical estimate, not a precise prediction."),
    (None, 10, "Vaginal pH in the newborn is:", "A) 5.7", "Vaginal pH of a newborn is ~5.7 (acidic), due to maternal oestrogen influence stimulating glycogen deposition and subsequent lactic acid production. This reverts to alkaline (~7.0) during childhood, then returns to acidic (~4.0–4.5) at puberty."),
    (None, 11, "Endometrial carcinoma is usually associated with all EXCEPT:", "D) Multiparity", "Risk factors include obesity, diabetes, hypertension, and unopposed oestrogen. Multiparity is PROTECTIVE — each pregnancy reduces endometrial cancer risk via progesterone exposure."),
    (None, 12, "HCG disappears from maternal urine after delivery within:", "C) 48 hours", "After placental delivery, hCG falls rapidly (half-life ~24–36 hours) and becomes undetectable in urine within 48–72 hours. C) 48 hours is the best answer among options."),
    (None, 13, "The total duration of pregnancy is:", "B) 280 days", "Normal pregnancy lasts 280 days (40 weeks) from the first day of the last menstrual period (LMP). This is the basis of Naegele's rule."),
    (None, 14, "Peak levels of HCG in the urine are seen after ... days of pregnancy:", "C) 70 days (~10 weeks)", "Serum and urine hCG peaks at ~60–70 days (8–10 weeks) of gestation. After this peak, hCG declines and plateaus through the remainder of pregnancy."),
    (None, 15, "Quickening can be felt at ... weeks:", "C) 16 weeks", "Quickening (first perception of fetal movement) occurs at 16–20 weeks. Earlier in multigravidas (~14–16 weeks), later in primigravidas (~18–20 weeks). 16 weeks is the standard exam answer."),
    (None, 16, "Hegar's sign can be elicited by:", "B) 10 weeks", "Hegar's sign (softening of the uterine isthmus on bimanual examination) is a probable sign of pregnancy, consistently demonstrable from ~6–10 weeks. B) 10 weeks is the standard answer."),
    (None, 17, "Commonest site of endometriosis:", "B) Ovary", "The ovary is the most common site (~80% of pelvic endometriosis), forming 'chocolate cysts' (endometriomas). Other sites: uterosacral ligaments, posterior cul-de-sac, broad ligament."),
    (None, 18, "Oral contraceptives are contraindicated in:", "E) All of the above", "OCPs are contraindicated in hypertension (stroke risk), thromboembolism (absolute contraindication — oestrogen increases clotting factors), fibroids (oestrogen promotes growth), and menorrhagia from some causes."),
    (None, 19, "The best method to confirm the diagnosis of carcinoma cervix is:", "C) Cervical biopsy", "Histological confirmation via cervical biopsy is the gold standard. Pap smear is a screening tool only. Colposcopy-directed biopsy is the standard approach when screening is abnormal."),
    (None, 20, "Note: Question 20 appears to be a printing error (repeated heading from Q19 with contraceptive options).", "B) High progestin pills (likely intended as emergency contraception question)", "The options (high oestrogen pills, high progestin pills, UCD, menstrual regulation) suggest an emergency contraception question. Modern choice: levonorgestrel (high progestin)."),
    (None, 21, "Deep transverse arrest occurs in ... pelvis:", "C) Android", "Deep transverse arrest occurs most commonly in the android pelvis — heart-shaped inlet, convergent sidewalls, narrow subpubic arch, and prominent ischial spines prevent internal rotation of the fetal head."),
    (None, 22, "Earliest menopausal symptom is:", "A) Hot flushes", "Hot flushes (vasomotor symptoms) are the earliest and most characteristic symptom of menopause, due to oestrogen withdrawal affecting the hypothalamic thermoregulatory centre. Osteoporosis is a long-term consequence."),
    (None, 23, "Most common chronic symptom of pelvic inflammatory disease is:", "A) Backache", "The most common chronic symptom of PID is chronic pelvic pain/backache caused by pelvic adhesions and scarring. Fever and dysuria are features of acute PID."),
    (None, 24, "Elderly women with recurrent swelling and pain of the vulva:", "B) Bartholin's cyst", "Bartholin's cyst or abscess at the posterior introitus causes recurrent vulvar swelling and pain. Important: in postmenopausal women, any new Bartholin's mass needs biopsy to exclude carcinoma."),

    # PAGE 2
    ("PAGE 2 (Q25–49)", None, None, None, None),
    (None, 25, "CCF is most likely in pregnancy at:", "C) 3rd stage of labour", "At placental delivery, ~500 ml of blood is auto-transfused back into maternal circulation (uteroplacental autotransfusion), causing a sudden increase in venous return. This is the peak cardiac stress — most dangerous moment for a woman with cardiac disease."),
    (None, 26, "A young girl shows severe dysplasia on vaginal cytology. Treatment of choice is:", "C) Colposcopy", "Severe dysplasia (high-grade SIL / CIN 2–3) on cytology requires colposcopy with directed biopsy as the next step to confirm histological grade before definitive treatment. Pap smear is screening; biopsy confirms diagnosis."),
    (None, 27, "Red degeneration of fibroid is associated with:", "A) Pregnancy", "Red (carneous) degeneration occurs almost exclusively during pregnancy (2nd trimester). Venous thrombosis and infarction within the fibroid occurs as the enlarging uterus outpaces blood supply. Presents with acute pain and fever; managed conservatively."),
    (None, 28, "Commonest cause of maternal mortality is:", "B) Bleeding PV (Haemorrhage)", "Obstetric haemorrhage (especially PPH) is the leading cause of maternal mortality worldwide, accounting for 25–35% of all maternal deaths globally, particularly in developing countries."),
    (None, 29, "The most common type of female pelvis is:", "A) Gynecoid", "The gynecoid pelvis is the most common female pelvic type (~50% of women). It has a rounded inlet, adequate dimensions, and is ideal for vaginal delivery. Android ~30%, Anthropoid ~20%, Platypelloid <3%."),
    (None, 30, "Most common cause of postpartum endometritis is:", "A) E. coli", "Postpartum endometritis is typically polymicrobial; E. coli and other gram-negative organisms are most commonly isolated, particularly after caesarean section."),
    (None, 31, "Labour is termed precipitate if it occurs under:", "B) 2 hours", "Precipitate labour is labour completed within 2 hours (some texts say 3 hours). More common in multiparous women; risks include perineal lacerations, PPH, and fetal distress."),
    (None, 32, "Longest diameter of the fetal skull is:", "C) Occipitomental", "The occipitomental diameter (~13.5 cm) is the longest diameter of the fetal skull (from occiput to chin). This presents in mentoposterior face presentation, explaining why vaginal delivery is impossible. Biparietal = 9.5 cm."),
    (None, 33, "Post-abortal sepsis causing renal failure is likely due to:", "C) Clostridium", "Clostridium welchii (perfringens) causes post-abortal sepsis via potent exotoxins producing massive haemolysis, haemoglobinuria, DIC, and acute tubular necrosis (renal failure). Classic in septic/criminal abortion."),
    (None, 34, "Average pressure of uterine contractions during first stage of labour:", "C) 20 mm Hg", "During the active first stage, average intrauterine pressure above resting tone during a contraction is ~20–30 mm Hg. Resting tone ~8–12 mm Hg; peak contraction 40–60 mm Hg. Most Indian texts cite 20 mm Hg."),
    (None, 35, "Ferning pattern of drying cervical mucus suggests the action of:", "A) Estrogen", "Oestrogen increases NaCl content of cervical mucus, causing fern-like crystalline patterns when dried. Maximal at mid-cycle. Progesterone opposes this, making mucus thick and cellular (no ferning)."),
    (None, 36, "Sexual development is considered precocious if breast/pubic hair growth before age:", "A) 8 years", "Precocious puberty is defined as secondary sexual characteristics before age 8 in girls (age 9 in boys). This is the standard WHO and paediatric endocrinology definition."),
    (None, 37, "Failure rate after tubal sterilization with Pomeroy's technique is:", "C) 0.4%", "The Pomeroy technique (ligation and excision of a tubal loop) has a failure rate of ~0.4% (4 per 1000) over 10 years. It is not zero — spontaneous reanastomosis can occur."),
    (None, 38, "Most frequent site of metastasis in choriocarcinoma is:", "C) Lungs", "Lungs are the most common metastatic site in gestational trophoblastic neoplasia (~70–80% of metastatic cases). Classic presentation: haemoptysis in a young woman after a pregnancy event. Vaginal mets are second most common (~30%)."),
    (None, 39, "Chemotherapy of choriocarcinoma is by:", "A) Methotrexate", "Methotrexate (folate antagonist) is first-line single-agent chemotherapy for low-risk choriocarcinoma, achieving >90% cure rates. Actinomycin-D is the alternative. High-risk disease uses EMA-CO combination regimen."),
    (None, 40, "Commonest site of primary carcinoma in Krukenberg ovarian tumour is:", "B) Stomach", "A Krukenberg tumour is a metastatic ovarian tumour from a GI primary — most commonly gastric carcinoma (~70%). Characterised histologically by mucin-filled signet-ring cells within ovarian stroma."),
    (None, 41, "Compound type of presentation is:", "B) Shoulder", "Shoulder presentation (transverse lie) is a malpresentation where vaginal delivery is impossible. Vertex is the normal presentation. Compound presentation strictly involves a limb prolapsing alongside the presenting part."),
    (None, 42, "Eclampsia is differentiated from pre-eclampsia by:", "B) Convulsions", "The defining feature distinguishing eclampsia from pre-eclampsia is the occurrence of grand mal convulsions (seizures). Pre-eclampsia already includes hypertension, proteinuria, and may include retinal changes."),
    (None, 43, "The earliest symptom of cervical cancer is:", "D) Leukorrhoea", "The earliest symptom of carcinoma cervix is leukorrhoea — a watery, blood-tinged, foul-smelling vaginal discharge from tumour necrosis. This precedes contact bleeding. Pain is a late symptom."),
    (None, 44, "Multiple births are commonest among:", "D) Negroes (Black Africans)", "Twin and higher-order pregnancies are most common among Black African populations — the Yoruba tribe in Nigeria has the highest natural twinning rate worldwide (~45–50 per 1000 births) due to higher natural FSH levels causing dizygotic twinning. Asians have the lowest rates."),
    (None, 45, "Commonest site of genital tuberculosis in women is:", "A) Tubes (Fallopian tubes)", "Fallopian tubes are affected in virtually 100% of female genital TB cases. Endometrium is second (~50–60%). TB reaches tubes haematogenously from a primary pulmonary focus. Tuberculous salpingitis is the major cause of tubal factor infertility."),
    (None, 46, "Spontaneous abortions commonly occur during the ... month:", "B) Second month", "~80% of spontaneous abortions occur in the first trimester, with peak incidence in the second month (6–10 weeks). Most common cause is chromosomal abnormality (~50–60% of first-trimester losses)."),
    (None, 47, "Amount of blood loss during each menstrual period is about:", "B) 35 cc", "Average menstrual blood loss is 35 ml per period (range 25–80 ml). Menorrhagia is defined as >80 ml per cycle. Goldman-Cecil Medicine confirms: 'average loss of 35 mL of blood and 16 mg of iron per menstrual period.'"),
    (None, 48, "Commonest manifestation of endometriosis is:", "B) Pain", "Pelvic pain is the most common symptom: dysmenorrhoea, chronic pelvic pain, dyspareunia, and dyschezia. Infertility is the second most common presentation. Leukorrhoea is NOT a feature of endometriosis."),
    (None, 49, "Lovset's manoeuvre is used to deliver:", "D) Arms", "Lovset's manoeuvre is used for delivery of extended/nuchal arms in breech delivery. It involves rotating the baby's trunk 180° while maintaining downward traction, bringing the posterior arm anteriorly so it can be swept down and delivered."),

    # PAGE 3
    ("PAGE 3 (Q50–74)", None, None, None, None),
    (None, 50, "Best contraceptive for a 20-year nulliparous woman is:", "B) Pills", "OCPs are ideal for a young nulliparous woman — highly effective (>99%), reversible, rapid return of fertility. IUCD is relatively contraindicated in nulliparous women (risk of expulsion, infection). Condoms and foam tablets have higher failure rates."),
    (None, 51, "Commonest complication of an ovarian teratoma (dermoid cyst) is:", "A) Torsion", "Torsion occurs in ~15% of dermoid cysts — they are mobile with a long pedicle and their oily/fatty content makes them buoyant, causing anterior tipping. Malignant transformation occurs in only ~1–2%."),
    (None, 52, "Endometriosis mostly occurs in ... women:", "D) Nulliparous", "Endometriosis predominantly affects nulliparous women of reproductive age. Pregnancy is protective via progesterone suppression of endometrial implants. Classic: young (25–35 years), nulliparous woman with dysmenorrhoea."),
    (None, 53, "Commonest cause of secondary amenorrhoea is:", "B) Pregnancy", "Pregnancy is by far the most common cause of secondary amenorrhoea and must always be excluded first before investigating any other cause."),
    (None, 54, "MTP is legal in pregnancy up to ... weeks:", "C) 20 weeks", "Under the original Indian MTP Act 1971, termination was legal up to 20 weeks. The MTP Amendment Act 2021 extended to 24 weeks for special categories. Classic exam answer remains 20 weeks."),
    (None, 55, "Cervical incompetence is treated by ... procedure:", "D) All of the above", "Cervical cerclage can be performed by: Shirodkar's (purse-string buried under mucosa), McDonald's (simpler purse-string, most common today), and Wurm procedure (mattress sutures). All are established cerclage techniques."),
    (None, 56, "Commonest complication of pregnancy in India:", "C) Anaemia", "Anaemia affects >50% of pregnant women in India (NFHS data) — the single most common complication. Iron deficiency predominates due to poor nutrition, multiple pregnancies, and inadequate supplementation."),
    (None, 57, "The length of the female urethra is:", "B) 40 mm", "The female urethra is ~4 cm (40 mm) long, extending from bladder neck to external urethral meatus. Its short length explains why women are far more susceptible to ascending UTIs compared to males (~20 cm urethra)."),
    (None, 58, "In transverse lie, presentation is:", "D) Shoulder", "In transverse lie, the fetal long axis lies perpendicular to the uterus; the presenting part is the shoulder/trunk. No vaginal delivery is possible; management is ECV or caesarean section."),
    (None, 59, "Maximum amount of amniotic fluid is seen at ... weeks:", "C) 32 weeks", "Amniotic fluid volume peaks at ~32–36 weeks (~800–1000 ml). After this it gradually decreases toward term (~600 ml at 40 weeks). The AFI is highest around 32–34 weeks."),
    (None, 60, "Cervical mucus shows palm leaf (ferning) pattern due to:", "B) Estrogens", "Oestrogen increases NaCl concentration in cervical mucus, which crystallises into fern-like patterns when dried. Maximal at mid-cycle ovulation. Progesterone converts mucus to thick, scanty, non-ferning form."),
    (None, 61, "Most life-threatening complication of septic abortion:", "B) Renal failure", "Acute renal failure (ATN) is the most life-threatening complication and principal cause of death in septic abortion — from Clostridial toxins causing massive haemolysis, endotoxic shock, and DIC, all converging on renal tubular injury."),
    (None, 62, "Internal podalic version is done under ... anaesthesia:", "D) General", "Internal podalic version requires complete uterine relaxation, achieved only under general anaesthesia (classically with halothane). Pudendal block, spinal, and IV sedation do not provide adequate uterine relaxation."),
    (None, 63, "Components of Meigs' syndrome are:", "D) All of the above", "Meigs' syndrome = triad of: (1) Fibroma of the ovary, (2) Ascites, (3) Hydrothorax (usually right-sided). All three resolve completely after surgical removal of the ovarian fibroma."),
    (None, 64, "Commonest cause of an unengaged head at term is:", "B) CPD (Cephalopelvic Disproportion)", "Non-engagement at term in a primigravida is most commonly due to CPD — the head is too large or the pelvis too contracted. In primigravidas, the head normally engages by 36–38 weeks; failure to engage requires assessment."),
    (None, 65, "Which type of eclampsia has the worst prognosis?", "B) Post-partum eclampsia", "Post-partum eclampsia (convulsions >24 hours after delivery, up to 4 weeks) carries the worst prognosis — often unsuspected, diagnosed late, and associated with more severe cerebral pathology with highest mortality."),
    (None, 66, "Sarcoma botryoides is mostly seen in:", "B) Children under 2 years", "Sarcoma botryoides (embryonal rhabdomyosarcoma of the vagina) occurs almost exclusively in infants and children <5 years (most commonly <2 years). It presents as a grape-like polypoid mass prolapsing from the vagina."),
    (None, 67, "Most common feature of cervicitis is:", "C) Leukorrhoea", "Leukorrhoea (mucopurulent vaginal discharge) is the most common presenting feature of cervicitis. Contact/post-coital bleeding is second. Dysmenorrhoea and infertility are not primary features."),
    (None, 68, "Longest anteroposterior diameter of the inlet is seen in ... pelvis:", "A) Anthropoid", "The anthropoid pelvis has a characteristically long AP diameter with narrow transverse diameter (oval/egg-shaped inlet). The AP diameter can measure 13+ cm. Platypelloid has the longest transverse but shortest AP."),
    (None, 69, "Commonest cause of retroverted uterus is:", "A) Congenital", "Congenital retroversion (uterus tilts posteriorly as normal anatomical variant) occurs in ~20% of women. Endometriosis and PID cause acquired/fixed retroversion but are less common than the congenital mobile type."),
    (None, 70, "Antihypertensive drug which inhibits labour:", "B) Diazoxide", "Diazoxide (K+ channel opener/vasodilator) used for hypertensive emergencies in pregnancy also inhibits uterine contractions (tocolytic effect) via the same K+ channel mechanism — an important clinical side effect."),
    (None, 71, "Sex determination in early pregnancy is done by:", "B) Amniocentesis", "Amniocentesis with chromosomal/karyotypic analysis is the standard method for definitive fetal sex determination (done at 15–18 weeks). CVS can be done earlier (10–13 weeks). Note: PCPNDT Act prohibits sex determination in India."),
    (None, 72, "Peg cells are seen in:", "D) Tubes (Fallopian tubes)", "Peg cells (secretory/non-ciliated intercalated cells) are found in the fallopian tube epithelium. They secrete fluid that nourishes the ovum, spermatozoa, and early embryo. The tubal epithelium has three cell types: ciliated, peg (secretory), and indifferent cells."),
    (None, 73, "At necropsy, pathognomonic lesions of eclampsia are seen in:", "C) Liver", "The liver shows the pathognomonic lesion at autopsy: periportal hepatic necrosis with haemorrhagic infarction — periportal fibrin deposition and haemorrhagic necrosis in the periphery of hepatic lobules. Specific enough to be pathognomonic."),
    (None, 74, "In which of the following is forceps used in the second stage of labour:", "B) Heart disease", "Forceps are used to shorten bearing-down efforts in women with cardiac disease — prolonged Valsalva manoeuvres dramatically increase cardiac workload and can precipitate acute decompensation in valvular disease or cardiomyopathy."),

    # PAGE 4
    ("PAGE 4 (Q75–100)", None, None, None, None),
    (None, 75, "Cystocele is formed by ... of the bladder:", "A) Base", "A cystocele (anterior vaginal wall prolapse) is formed by herniation of the base (posterior wall/floor) of the bladder through the anterior vaginal wall when the pubocervical fascia weakens."),
    (None, 76, "Daily caloric needs in pregnancy is about ... cal.:", "C) 2500", "Recommended daily caloric intake during pregnancy is ~2500 kcal/day (an increase of ~300 kcal/day above the non-pregnant baseline of ~2200 kcal). Lactation requires ~2700 kcal/day."),
    (None, 77, "FSH is secreted by:", "C) Anterior Pituitary", "FSH is secreted by gonadotroph cells of the anterior pituitary gland, under stimulation from hypothalamic GnRH. The ovary produces oestrogen/progesterone. The hypothalamus produces GnRH (the releasing hormone for FSH/LH)."),
    (None, 78, "Which of the following are uterine relaxants?", "D) All of the above", "All three are uterine relaxants: Isoxsuprine (beta-adrenergic agonist — original tocolytic), Alcohol/ethanol (inhibits oxytocin release from posterior pituitary — historically used), Salbutamol (beta-2 agonist — relaxes uterine smooth muscle)."),
    (None, 79, "Immediately following delivery, the height of the uterus corresponds to ... weeks:", "B) 20 weeks", "After delivery, the uterine fundus is at the level of the umbilicus, corresponding to a 20-week sized uterus. Involution proceeds at ~1 cm/day below the umbilicus; uterus returns to pre-pregnancy size by 6 weeks postpartum."),
    (None, 80, "Least common type of pelvis is:", "D) Platypelloid", "Platypelloid (flat) pelvis is the rarest pelvic type, found in <3% of women. It has a wide transverse but very short AP diameter giving a kidney-shaped inlet. Gynecoid ~50%, Android ~30%, Anthropoid ~20%."),
    (None, 81, "Organ which is affected least in IUGR:", "D) Brain", "In IUGR, the classic 'brain-sparing effect' redistributes blood flow preferentially to the brain, heart, and adrenals. The brain is LEAST affected (most protected). The liver is most affected (reduced glycogen, reduced size)."),
    (None, 82, "One pint of blood raises the haemoglobin by:", "C) 1 g%", "One pint (~450–500 ml) of whole blood raises Hb by ~1 g/dL. Standard clinical rule: 1 unit whole blood = +1 g/dL Hb; 1 unit packed red cells = +1–1.5 g/dL Hb."),
    (None, 83, "What type of uterine contraction is responsible for cervical ripening:", "A) A waves", "A waves (Caldeyro-Barcia) are small, low-amplitude (3–4 mmHg), localised contractions of the lower uterine segment/cervix responsible for cervical ripening and effacement. B waves (Braxton Hicks) are larger fundal contractions of active labour."),
    (None, 84, "In breech, engagement takes place earliest in:", "A) Frank breech", "In frank breech (hips flexed, knees extended — ~65% of breeches), the extended legs act as a splint making the presenting diameter compact and cylindrical, facilitating earlier engagement. Footling/knee breeches do not engage as readily."),
    (None, 85, "Post-pill amenorrhoea is treated by:", "D) Clomiphene", "Clomiphene citrate (SERM) blocks hypothalamic oestrogen receptors, increasing GnRH and FSH/LH secretion to induce ovulation. Simply giving oestrogens or progesterone does not restart the HPO axis. Bromocriptine if hyperprolactinaemia co-exists."),
    (None, 86, "Constriction ring in uterus is seen in:", "A) Obstructed labour", "Bandl's pathological retraction ring is seen in obstructed labour — a sign of impending uterine rupture. The junction between upper contractile and lower passive segment rises progressively. Obstetric emergency."),
    (None, 87, "Episiotomy is best done:", "C) Mediolaterally", "Mediolateral episiotomy avoids the anal sphincter and rectum (reduced risk of 3rd/4th degree tears vs. median), provides adequate space for delivery, and heals well. Preferred in UK obstetrics and developing countries."),
    (None, 88, "Uterine-cervix ratio up to 10 years of age is:", "D) 1:2", "In childhood, the cervix is larger than the uterine body. Uterus:cervix = 1:2 (cervix twice as long as corpus) at birth/childhood. At puberty it reverses to 2:1. In reproductive age: 2:1 to 3:1."),
    (None, 89, "Commonest site of implantation of ectopic pregnancy:", "B) Ampulla", "The ampullary portion of the fallopian tube is the most common site of ectopic pregnancy (~70–80%). Other sites: isthmus ~12%, fimbrial ~5%, interstitial ~2%, ovarian ~1%, abdominal <1%."),
    (None, 90, "Tumours arising from ovarian connective tissue:", "A) Fibroma", "Fibroma is a benign tumour from ovarian stromal (connective tissue/fibroblast) cells — a sex cord-stromal tumour. Classic association: Meigs' syndrome (fibroma + ascites + hydrothorax). Dysgerminoma = germ cell; Cystadenoma = surface epithelium."),
    (None, 91, "Maximum action of corpus luteum is at ... days after menstruation:", "D) 22 days", "In a 28-day cycle, ovulation is on day 14. The corpus luteum reaches peak progesterone production ~day 21–22 (7–8 days after ovulation) — the 'window of implantation.' It degenerates by days 24–26 if no fertilisation."),
    (None, 92, "Uterine relaxants of a term uterus:", "C) Salbutamol", "Oxytocin and prostaglandins CONTRACT the uterus (uterotonics). Salbutamol is a beta-2 agonist that RELAXES uterine smooth muscle (tocolytic). Diazoxide also relaxes uterus but is primarily an antihypertensive."),
    (None, 93, "Maternal antibodies are present against all diseases EXCEPT:", "E) Pertussis", "Whooping cough (Bordetella pertussis) does NOT provide adequate transplacental immunity to newborns. Tdap vaccination at 27–36 weeks is therefore recommended in pregnancy. Neonates are particularly vulnerable to pertussis."),
    (None, 94, "The size of ovum is:", "A) 0.133 mm", "The human ovum measures ~0.133–0.14 mm (133–140 micrometres) in diameter — the largest human cell, just barely visible to the naked eye."),
    (None, 95, "The length of fallopian tube is:", "B) 10–12 cm", "The fallopian tube is ~10–12 cm long: interstitial 1–2 cm, isthmus ~2–3 cm, ampulla ~5–6 cm (longest), infundibulum ~1–2 cm. Fertilisation normally occurs in the ampulla."),
    (None, 96, "Post-coital test is used to assess:", "A) Cervical factor", "The Sims-Huhner post-coital test evaluates the cervical factor in infertility — specifically sperm-cervical mucus interaction. Performed 2–8 hours after intercourse at mid-cycle. Normal: >20 motile sperm/HPF."),
    (None, 97, "Amniotic fluid embolism causes:", "D) All", "AFE is a catastrophic emergency causing: Shock (sudden cardiovascular collapse), DIC (amniotic fluid thromboplastic substances trigger coagulation), and Bleeding tendency (consumptive coagulopathy from DIC). All three are classical features."),
    (None, 98, "Gonococcal vulvovaginitis occurs in:", "B) Children", "Gonococcal vulvovaginitis affects prepubertal girls — the thin, non-oestrogenised vaginal epithelium is susceptible to N. gonorrhoeae. In adults, gonorrhoea causes cervicitis/PID. In children, this is highly suggestive of sexual abuse."),
    (None, 99, "Ideal contraceptive for recently married couple is:", "B) OCP", "OCPs are ideal for a recently married couple wishing to delay pregnancy — highly effective (>99%), fully reversible with rapid return of fertility, convenient, non-intercourse-dependent. IUCD less ideal for nulliparous; other options less effective."),
    (None, 100, "In papillary adenocarcinoma of the uterine cornua, lymphatic spread will occur to ... nodes:", "D) Paraaortic", "The uterine cornua (fundal region) drains via ovarian lymphatics along the infundibulopelvic ligament to paraaortic (lumbar) nodes at the level of the renal vessels — not to iliac nodes. Important for surgical staging and radiotherapy planning."),
]

# ─── BUILD STORY ─────────────────────────────────────────────────────────────
for item in data:
    section, qno, question, answer, explanation = item

    if section is not None:
        story.append(Spacer(1, 0.2*cm))
        story.append(Paragraph(f"  {section}", section_style))
        story.append(Spacer(1, 0.15*cm))
        continue

    if qno is None:
        continue

    # Question
    story.append(Paragraph(f"Q{qno}. {question}", q_style))
    # Answer
    story.append(Paragraph(f"Answer: {answer}", ans_style))
    # Explanation
    story.append(Paragraph(explanation, exp_style))

# ─── FOOTER TABLE ─────────────────────────────────────────────────────────────
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="100%", thickness=1.5, color=colors.HexColor('#1a1a6e'), spaceAfter=6))
story.append(Paragraph("Sources: Berek & Novak's Gynecology · Robbins & Kumar Basic Pathology · Creasy & Resnik's Maternal-Fetal Medicine · Goldman-Cecil Medicine · Guyton & Hall Medical Physiology · Harrison's Principles of Internal Medicine · Tietz Textbook of Laboratory Medicine · Bailey & Love's Short Practice of Surgery · Katzung's Basic & Clinical Pharmacology · The Developing Human (Moore & Persaud)", note_style))

doc.build(story)
print("PDF generated successfully!")

cd /home/daytona/workspace/gynaecology-mcq && python generate_pdf.py

ls -lh /home/daytona/workspace/gynaecology-mcq/