Hyperemesis gravidarum — structured oral station (12 minutes)

Opening prompt — "Walk me through your assessment and your first prescription."

Model response — say it in this order: ^[1][2]

• "She meets the Windsor definition of hyperemesis gravidarum: onset before 16 weeks, severe nausea and vomiting, inability to eat or drink normally, and strong limitation of daily activities. I would calculate her PUQE-24 to grade severity and chart it."
• "I would assess volume clinically — pulse, postural blood pressure, mucosae, urine output — and weigh her against her pre-pregnancy weight."
• "I would admit her, give intravenous sodium chloride 0.9% with potassium chloride in each bag guided by daily electrolytes, give thiamine before any dextrose, prescribe first-line antiemetics regularly, and assess her VTE risk."

Examiner is listening for: an objective severity score, the right fluid, thiamine before glucose, regular antiemetic prescribing, and a VTE assessment. ^[1]

Probe 1 — "Her ketones are 3+. Does that change her severity grading?"

• "No. 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. Her severity is graded by PUQE-24 and by her clinical state, not by her ketone dipstick."
• "I would still check capillary ketones and glucose — but to exclude diabetic ketoacidosis as a differential, not to grade the hyperemesis."^[1]

Probe 2 — "Two days in, she develops double vision and confusion. What is happening and what do you do?"

• "I am worried about Wernicke encephalopathy — confusion plus eye signs in a woman who has vomited for weeks. This is a same-hour diagnosis."
• "Hold any dextrose or parenteral nutrition, give parenteral high-dose thiamine immediately — adequate treatment is defined in the systematic review as more than 500 mg per day intramuscularly or intravenously — and involve neurology and MRI urgently."^[3]
• "In that review of 177 cases, intravenous glucose exacerbated Wernicke encephalopathy in 14.1%, chronic cognitive disorder followed in 65.4%, pregnancy loss in 50%, and maternal death in 5%. This is the complication I am trying to prevent by giving thiamine on admission."^[3]

Probe 3 — "She asks whether ondansetron will harm her baby. What do you tell her?"

• "Green-top 69 says ondansetron is safe and effective and its use as a second-line agent should not be discouraged. I would give her the absolute numbers."
• "In the Huybrechts Medicaid cohort of over 1.8 million pregnancies, oral clefts occurred in 11.1 per 10 000 unexposed versus 14.0 per 10 000 exposed — an adjusted relative risk of 1.24, an adjusted risk difference of about 3 per 10 000. There was no signal for cardiac malformations or congenital malformations overall."^[4]
• "I would frame it as: about three extra babies with a cleft per ten thousand women treated, on top of about eleven who would have had one anyway — balanced against the real risks of poorly managed hyperemesis."^[1][4]

Probe 4 — "She says she is thinking about ending the pregnancy. How do you respond?"

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1][5]

• Move to her eye level, acknowledge the courage it took to say it, and ask what is driving the thought today.
• Separate the illness from the pregnancy: "What I am hearing is that you cannot survive feeling like this — not that you do not want this baby. Those are different problems, and one of them I can treat."
• Name what has not yet been tried — the rung of the ladder not reached, the dietitian not seen, the day unit not used.
• Screen explicitly for suicidal ideation and act on the answer; refer to perinatal mental health the same day where indicated.
• State the guideline position: all therapeutic measures should have been tried before termination of pregnancy is considered (Grade C). Document and offer a second consultation; do not coerce in either direction.^[1][5]

Probe 5 — "What is the evidence base for the treatments you are using?"

• "The Cochrane review of 25 trials and 2052 women found little high-quality evidence for any single intervention, with one useful signal: corticosteroids reduced readmission, risk ratio 0.69, 95% CI 0.50 to 0.94."^[6]
• "For ondansetron safety, the Huybrechts JAMA cohort is the contemporary reference; for the corticosteroid regimen I would use, the CMAJ 2024 practice review specifies hydrocortisone 100 mg every 12 hours intravenously, switching to oral prednisolone 40 mg day 1, 20 mg days 2 to 3, 10 mg days 4 to 6, 5 mg days 7 to 14."^[4][7]

Probe 6 — "What is her prognosis, and what do you tell her about the next pregnancy?"

• "Most women improve with the ladder climbed correctly; a real minority carry symptoms to term and need to be believed."
• "Recurrence is high: cohort studies report 15 to 81%, and prospective follow-up of the MOTHER cohort found 89% recurrence. Counsel honestly and offer prepregnancy planning — a written plan, first-line antiemetics started at the first symptom, and a named clinician."^[6][8]