Hyperemesis gravidarum — structured SAQ (15 marks)

(a) PUQE-24 scoring and classification (3 marks)

One mark for correctly scoring each of the three items; classification follows from the total. ^[3]

• Item 1 — nausea duration over the last 24 hours: score 1 to 5 (not at all = 1; 1 hour or less = 2; 2 to 3 hours = 3; 4 to 6 hours = 4; more than 6 hours = 5).
• Item 2 — vomiting episodes: score 1 to 5 (none = 1; 1 to 2 = 2; 3 to 4 = 3; 5 to 6 = 4; 7 or more = 5).
• Item 3 — retching episodes: score 1 to 5 (none = 1; 1 to 2 = 2; 3 to 4 = 3; 5 to 6 = 4; 7 or more = 5).
• Total runs 3 to 15; bands: 3 no NVP, 4 to 6 mild, 7 to 12 moderate, 13 or more severe. With her history she is in the severe band (13 or more) — she meets the Windsor definition of hyperemesis gravidarum.^[1][2][3]

(b) Immediate inpatient management (5 marks)

One mark per correctly specified element with drug, dose and route; the thiamine rule is non-negotiable. ^[1]

• Intravenous fluid: sodium chloride 0.9% with additional potassium chloride in each bag, administration guided by daily electrolyte monitoring (Grade C). Dextrose-containing fluids are the wrong answer — they precipitate Wernicke encephalopathy and worsen hyponatraemia.
• Thiamine before any glucose: oral thiamine 100 mg three times daily, or intravenous thiamine as part of a vitamin B complex (Pabrinex), given to all women admitted with vomiting or severely reduced dietary intake and specifically before dextrose or parenteral nutrition (Grade D).
• First-line antiemetics, prescribed regularly not as required: doxylamine 10 mg with pyridoxine 10 mg every 6 hours, or cyclizine 50 mg every 8 hours, or promethazine 25 mg every 8 hours (Grade A).^[7]
• Second-line, if first line fails: metoclopramide 10 mg every 8 hours (intravenous doses by slow bolus over at least 3 minutes, Grade C) and ondansetron 4 mg every 8 hours (Grade B).^[7]
• Thromboprophylaxis: assess VTE risk on admission — dehydration plus immobility plus pregnancy stack together; prescribe mechanical and pharmacological prophylaxis per local policy where indicated.^[1][7]

(c) Ketones and severity (2 marks)

One mark for the correct position; one for the grade. ^[1]

• Green-top Guideline 69 second edition states at Grade A that ketonuria is not an indicator of dehydration and should not be used to assess severity.
• The 4+ ketones in this woman do not grade her hyperemesis; her PUQE-24 and her clinical state do. Capillary ketones remain useful for excluding ketoacidosis as a differential, not for severity grading.^[1]

(d) Ondansetron counselling numbers (3 marks)

One mark for the cohort; one for the cleft numbers; one for the cardiac/malformation numbers. ^[4]

• The numbers come from a US Medicaid cohort of 1 816 414 pregnancies, of which 88 467 were exposed to ondansetron in the first trimester.
• Oral clefts: 11.1 per 10 000 births unexposed versus 14.0 per 10 000 exposed — adjusted relative risk 1.24 (95% CI 1.03 to 1.48), adjusted risk difference 2.7 per 10 000 (95% CI 0.2 to 5.2).
• Cardiac malformations: no association, adjusted relative risk 0.99 (95% CI 0.93 to 1.06). Any congenital malformation: adjusted relative risk 1.01 (95% CI 0.98 to 1.05).
• Counsel in plain numbers: about three extra babies with a cleft per ten thousand women treated, on top of about eleven who would have had one anyway — against the real risks of poorly managed hyperemesis.^[4][1]

(e) Managing the request to end the pregnancy (2 marks)

One mark for the stance; one for the guideline sentence. ^[1][6]

• Open without judgement; separate the illness from the pregnancy ("you cannot survive feeling like this, not that you do not want this baby"); screen explicitly for suicidal ideation and act on the answer; name the rung of the ladder not yet climbed; document and offer a second consultation; do not coerce in either direction.
• The guideline position: all therapeutic measures should have been tried before termination of pregnancy is considered (Grade C). The evidence base for that stance: in a cohort of 808 women with hyperemesis, 15.2% had ended a pregnancy because of it, and the modifiable driver was care experience.^[1][6][8]