What is the severity of this patient's Hyperemesis Gravidarum (HG)?

Severity Assessment of Hyperemesis Gravidarum

This patient has moderate hyperemesis gravidarum that is showing signs of clinical improvement. The fact that she is bedridden indicates significant functional impairment, but her improving mood and renewed interest in food after weeks of symptoms suggest she is transitioning from severe to moderate disease 1.

Clinical Reasoning for Severity Classification

Evidence Supporting Moderate (Not Severe) Classification

• Improving trajectory is key: The patient's mood improvement and first interest in food in weeks indicates she is responding to treatment and moving away from severe disease 1, 2
• Functional status alone is insufficient: While being bedridden suggests significant impairment, this must be interpreted in context with other clinical parameters 1
• Severe HG indicators that appear absent: Truly severe cases require consideration of enteral feeding (nasojejunal tube) or parenteral nutrition when patients have ≥5-7 vomiting episodes daily despite maximal antiemetics, progressive weight loss ≥5% of pre-pregnancy weight, or inability to maintain oral intake of 1000 kcal/day for several days 1, 3

Why Not Mild

• Mild HG patients are not bedridden: Patients with mild disease can typically maintain activities of daily living with dietary modifications and first-line antiemetics (doxylamine-pyridoxine) 1, 2
• Duration of symptoms: Weeks of symptoms severe enough to eliminate interest in food indicates this exceeded mild disease 1

Why Not Severe

• Interest in food is a critical turning point: Severe refractory HG patients cannot tolerate oral intake and require escalation to third-line therapy (methylprednisolone 16 mg IV every 8 hours) or alternative routes of nutrition 1, 2
• Severe cases require hospitalization: Patients with severe refractory HG need continuous IV therapy, around-the-clock scheduled antiemetics (not PRN dosing), and often multidisciplinary involvement including maternal-fetal medicine, gastroenterology, and nutrition services 1

Recommended Management Approach

Immediate Assessment Priorities

• Use PUQE score serially: Track symptom severity objectively to confirm the improving trajectory 1, 2
• Check for complications of prolonged disease: Electrolyte panel (particularly potassium and magnesium), liver function tests, urinalysis for ketonuria 1, 2
• Assess thiamine status: After weeks of poor intake, check for signs of Wernicke encephalopathy (confusion, ataxia, eye movement abnormalities) and ensure thiamine 100 mg daily for minimum 7 days 1, 2

Treatment Optimization

• Capitalize on the improvement window: Since she's showing interest in food, advance diet slowly with small, frequent bland meals (BRAT diet: bananas, rice, applesauce, toast) 1
• Ensure adequate antiemetic coverage: If not already on it, doxylamine-pyridoxine combination should be continued as maintenance therapy 1, 2
• Avoid premature discontinuation: The recurrence risk is 40-92% in subsequent pregnancies, and 10% of patients experience symptoms throughout pregnancy, so maintain vigilance 1, 2

Common Pitfalls to Avoid

• Don't undertreat based on subjective improvement alone: Verify with objective measures (weight trend, ability to maintain 1000 kcal/day oral intake, PUQE score) 1
• Don't miss refeeding syndrome risk: After prolonged poor intake, advance nutrition slowly and monitor electrolytes closely, particularly phosphate 1
• Don't assume resolution: 80% of patients improve by week 20, but this patient may be in the 10% with persistent symptoms—continue monitoring 1, 2