How would you rate the severity of hyperemesis gravidarum (HG) in a patient with significant weight loss, prolonged bed rest, and severe symptoms, including persistent nausea and prolonged cramps after eating, despite failed first-line treatments with Zofran (ondansetron), B6/Unisom, and oral Reglan (metoclopramide)?

Severity Classification of This Patient's Hyperemesis Gravidarum

This patient has severe hyperemesis gravidarum based on the 14% pre-pregnancy weight loss (far exceeding the 5% threshold), extreme functional impairment with 18-23 hours daily bed rest, and failure of multiple first-line and second-line therapies. 1

Objective Severity Criteria Met

This patient clearly meets multiple criteria for severe HG:

• Weight loss of 14% of pre-pregnancy weight - This dramatically exceeds the ≥5% threshold that defines HG itself, and represents profound nutritional compromise requiring aggressive intervention 1, 2

• Extreme functional impairment - Being bedridden 18-23 hours daily represents near-complete loss of quality of life and inability to perform activities of daily living, which is a hallmark of severe disease 1

• Treatment failure across multiple medication classes - She has failed ondansetron (5-HT3 antagonist), vitamin B6/doxylamine (first-line therapy), and metoclopramide (dopamine antagonist/second-line agent), indicating refractory disease 1, 2

• Requirement for twice-weekly IV hydration - The need for ongoing parenteral fluid replacement indicates inability to maintain adequate oral intake and persistent dehydration 1

• NJ tube offered - The clinical team's consideration of enteral feeding tube placement itself signals recognition of severe disease with inadequate nutritional intake despite maximal medical therapy 1

PUQE Score Limitations in This Case

While the PUQE (Pregnancy-Unique Quantification of Emesis) score is recommended for severity assessment, it has significant limitations in this patient 1, 2:

• PUQE focuses primarily on vomiting frequency - This patient paradoxically does not vomit currently, yet has severe persistent nausea and profound functional impairment 2

• PUQE may underestimate severity - Research shows PUQE classified only 58% of women reporting "nothing goes or stays down" as severe, compared to 92% using the HELP Score, which better captures functional impairment 3

• Weight loss and functional status are more objective markers - The 14% weight loss and near-complete bed rest are unambiguous indicators of severe disease regardless of vomiting frequency 1

Clinical Context Supporting Severe Classification

Several additional factors confirm severe disease:

• Prolonged cramping after eating (8+ hours) - This represents severe gastrointestinal dysfunction preventing adequate oral nutrition 1

• Daily diarrhea with severe temporary cramps - These symptoms suggest electrolyte disturbances and malabsorption, common in severe HG 1

• Initiation of corticosteroids - Prednisolone is reserved as third-line therapy for severe refractory HG when first-line (B6/doxylamine) and second-line agents (metoclopramide, ondansetron) have failed 1, 2

Critical Management Gaps to Address

Despite appropriate corticosteroid initiation, several concerning issues require immediate attention:

• Twice-weekly IV fluids are likely inadequate - Severe HG with this degree of weight loss and functional impairment typically requires continuous or daily IV hydration, not intermittent twice-weekly boluses 1

• Thiamine supplementation is essential - With prolonged poor intake and 14% weight loss, she is at high risk for Wernicke's encephalopathy and requires thiamine 200-300 mg IV daily immediately, not just oral supplementation 1

• Electrolyte monitoring is critical - Daily diarrhea and prolonged poor intake place her at risk for hypokalemia, hypomagnesemia, and refeeding syndrome when nutrition is reintroduced 1

• Consider hospitalization for continuous therapy - The combination of severe weight loss, treatment failure, and consideration of NJ tube placement suggests she may benefit from inpatient management with continuous IV fluids, around-the-clock scheduled antiemetics (not PRN), and close monitoring 1

Common Pitfall to Avoid

Do not be misled by the absence of active vomiting - Severity is determined by weight loss, functional impairment, and treatment response, not vomiting frequency alone. This patient's 14% weight loss and near-complete bed rest definitively classify her as severe HG regardless of current vomiting patterns 1, 3