GPAtlas🧭 When to suspect (and how to grade severity)
Nausea and vomiting in pregnancy (NVP) affects up to 80% of pregnancies. It typically begins between 4 and 7 weeks' gestation, peaks around 9 weeks, and settles by 16–20 weeks in most women – though a minority have symptoms that persist to term.
Hyperemesis gravidarum (HG) is the severe end of the spectrum (around 1–3% of pregnancies): a clinical diagnosis of exclusion characterised by persistent, severe nausea and vomiting, weight loss (usually > 5% of pre-pregnancy body weight), dehydration and electrolyte imbalance. The core primary-care skills are to grade severity, exclude an alternative cause, and treat early and adequately – antiemetics are safe and undertreatment drives relapse and admission.
Severity is graded with a validated tool, the Pregnancy-Unique Quantification of Emesis (PUQE) score (range 3–15). Importantly, the 2024 RCOG guideline confirms that ketonuria is not a marker of dehydration or severity and should no longer be used to guide management.
| PUQE-24 score | Severity | Typical setting / action |
|---|---|---|
| ≤ 6 | Mild | Primary care – reassurance, dietary advice, first-line antiemetic if needed |
| 7–12 | Moderate | Primary care / ambulatory – antiemetics; consider ambulatory IV fluids if not tolerating oral |
| ≥ 13 | Severe | Refer for ambulatory or inpatient IV fluids and antiemetics |
Source: RCOG Green-top Guideline No. 69
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