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239) Definite: Extra-uterine embryo with cardiac activity (seen in 15-20% of ectopic pregnancies) Suggestive: Free pelvic or Intra-peritoneal fluid, tubal ring, complex adnexal mass Incidence of heterotopic (ectopic + IUP) in General population: 1:4,000-30,000 Incidence in assisted reproduction: 1 in 100, therefore cannot exclude ectopic and further work-up needed in this population Treatment of Ectopic Pregnancy Unstable Treat as ruptured ectopic Clinical: Severe abdominal pain, peritonitis, hypotension/shock FAST US: Intraperitoneal free fluid, complex adnexal mass Type and Cross vs transfusion Emergent GYN consult for OR Stable Expectant management Indication: unknown location pregnancy or suspected ectopic with low/declining -HCG Contraindications: Risk factors for rupture (increasing abdominal pain), not able to follow-up, and lack of timely access to medical care Methotrexate See table for indications Surgery Indications: Hemodynamic instability, contraindications to methotrexate, suspicion or risk factors for rupture, or failed medical therapy 3

The Energy Pathways To understand better where we get energy to exercise (or any physical activity), heres a short lesson on energy production