PUQE Score — Pregnancy Nausea Severity

What is the PUQE score?

PUQE-24 (Pregnancy-Unique Quantification of Emesis, 24-hour version) — 3-question validated scale grading nausea and vomiting in pregnancy on a scale of 3-15. Used worldwide to triage symptoms and track treatment response. Asks about hours of nausea, vomiting episodes, and retching episodes in the last 24 hours. Takes 2 minutes.

What do PUQE scores mean?

• 3-6 (mild): manage with diet, ginger, B6, rest. Most pregnant women.
• 7-12 (moderate): prescription antiemetics, hydration support, possibly day-case IV fluids.
• 13-15 (severe): highly suggestive of hyperemesis gravidarum. Urgent clinical care; IV fluids, IV antiemetics, possible admission.

What is hyperemesis gravidarum?

Severe pregnancy nausea and vomiting causing dehydration, weight loss, electrolyte imbalance, ketosis. ~1-3% of pregnancies. NOT just bad morning sickness — distinct clinical entity. RCOG diagnostic criteria: persistent vomiting + weight loss ≥ 5% pre-pregnancy weight + ketonuria + electrolyte abnormalities. Can be life-threatening untreated (Wernicke’s from B1 deficiency, Mallory-Weiss tears from retching). NEEDS treatment.

What helps at home (mild)?

• Small frequent meals every 2-3 hours.
• Bland foods first thing — crackers, dry toast before getting up.
• Ginger (tea, biscuits, capsules) — Cochrane-reviewed evidence.
• Avoid trigger smells — cooking, perfume, certain foods.
• Cold foods often better tolerated.
• Stay hydrated — sip electrolyte drinks if vomiting.
• Acupressure wrist bands — mixed evidence; low harm.
• Vitamin B6 / pyridoxine 10-25 mg 3x/day — good evidence.
• Rest.

Prescription antiemetics (moderate-severe)

• Doxylamine + pyridoxine (Diclectin / Diclegis / Xonvea) — FDA pregnancy category A. First-line.
• Cyclizine — UK first-line, ~50 mg every 8h.
• Promethazine — sedating antihistamine; useful at night.
• Metoclopramide — dopamine antagonist; UK limited to 5 days.
• Ondansetron — strong efficacy; small risk of cleft palate at < 10 weeks; QT caution.
• Prochlorperazine (Stemetil) — common UK.
• Oral prednisolone — severe resistant HG.

When to go to A&E or maternity unit

Same-day urgent care if:

• Can’t keep ANY fluids down for 4+ hours.
• Signs of dehydration (dizzy, fainting, very dry mouth, no urine for 8+ hours).
• Vomiting blood (Mallory-Weiss tear from retching).
• Severe abdominal pain.
• Severe headache or vision changes.
• Confusion or hallucinations (Wernicke’s).
• Not improving on oral antiemetics.
• Weight loss > 5% of pre-pregnancy.

How long does pregnancy nausea last?

• Typical window: 4-12 weeks.
• Peak: 8-10 weeks.
• Resolution: 12-14 weeks for ~80%.
• ~20% have ongoing nausea past 20 weeks.
• ~5% nauseated throughout pregnancy.
• HG: often persists into second trimester or whole pregnancy.
• After delivery: resolves immediately.

Different scenarios — what your score means

Scenario 1: PUQE 5 at 7 weeks, can eat small meals, mild vomiting morning only

Mild. Tier 1 measures — small frequent meals, ginger, B6. Will likely improve by 14 weeks.

Scenario 2: PUQE 9 at 10 weeks, vomiting 4-5x/day, can keep some fluids down

Moderate. GP visit for cyclizine or doxylamine/B6. Monitor weight, urine output. If not improving in a week, escalate.

Scenario 3: PUQE 14 at 12 weeks, can't keep anything down, lost 4 kg

Likely hyperemesis gravidarum. Same-day maternity unit / A&E. IV fluids, IV antiemetics (ondansetron, cyclizine), urine ketones, electrolytes. Likely 24-hour admission for stabilisation.

Scenario 4: Second pregnancy, had HG last time, currently 6 weeks and starting nausea

80% recurrence risk. Pre-emptive doxylamine/B6 reasonable. Early antenatal review. Emergency plan ready. Don’t wait until severe to seek help.

Scenario 5: Nausea since week 6, now 22 weeks, still vomiting daily

Prolonged NVP. Continue antiemetics. Worth reviewing — rule out other causes (UTI, thyroid, gallbladder, twin pregnancy). Continue antiemetic plan; usually settles by 28 weeks for most.

Care guidance — surviving pregnancy nausea

• Pre-emptive eating — small protein-rich snack every 2 hours; never let blood sugar drop.
• Crackers by the bed — eat 2 before getting up.
• Mild-flavour toothpaste (kids’ or sensitive).
• Stay hydrated — small sips constantly; ice chips if struggling.
• Ginger — tea, biscuits, capsules, ginger ale (real ginger).
• Avoid trigger smells — cook outside if needed; partner cooks; takeaway / frozen meals temporarily.
• Fresh air, cool room, lying down on side.
• B6 10-25 mg 3x/day.
• Don’t feel guilty for not eating “perfectly”.
• Time off work if you need it — not weakness.
• Mental health — severe nausea is exhausting and demoralising. Look after yours.
• Reach out — Pregnancy Sickness Support UK / HER Foundation US.

Common myths debunked

• “It’s just morning sickness, push through” — severe nausea / HG is a medical condition needing treatment.
• “Antiemetics will harm baby” — commonly-used antiemetics have decades of safety data; the bigger risk is untreated severe nausea.
• “Bad nausea = healthy pregnancy” — mild NVP is associated with lower miscarriage; SEVERE HG is a problem to TREAT, not celebrate.
• “It’s only morning sickness” — many women have nausea all day, not just morning.
• “Saltines and ginger should be enough” — for mild, yes. For HG, no.

Sources

• Koren G, et al. Validation studies of the Pregnancy Unique-Quantification of Emesis (PUQE) scores. J Obstet Gynaecol 2005.
• RCOG Green-top Guideline No. 69. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum.
• NICE CKS. Nausea/vomiting in pregnancy.
• ACOG Practice Bulletin 189. Nausea and Vomiting of Pregnancy.
• Pregnancy Sickness Support UK. Treatment guidance.
• HER Foundation. Hyperemesis Education and Research Foundation.