“I’m 9 weeks pregnant and can’t keep anything down — not even water — I feel awful and I’m scared”

Distinguish ordinary nausea/vomiting of pregnancy (NVP) from HYPEREMESIS GRAVIDARUM — RCOG Green-top Guideline No. 69 (2024), using the Windsor definition (international): onset before 16 weeks, nausea and vomiting with at least one severe, INABILITY to eat and/or drink normally and strong limitation of daily activities, with DEHYDRATION signs contributing (replacing the older triad of >5% weight loss, dehydration and electrolyte disturbance) — because inability to keep down even fluids, reduced urine output, light-headedness and weight loss mark a serious condition, not "just morning sickness". Assess severity objectively with the PUQE score, dehydration signs (tachycardia, postural drop, dry mucous membranes — assessed face to face, not on video — and reduced urine output), weight loss versus booking weight, the ability to tolerate oral fluids and antiemetics, and U&E (electrolytes/AKI) — not KETONURIA, which RCOG 2024 says is not an indicator of dehydration — the key practical discriminator being whether she can keep ORAL FLUIDS down. Decide DISPOSITION on severity: inability to tolerate fluids or oral antiemetics, clinical dehydration, abnormal electrolytes, or failure of community antiemetics warrants referral for IV REHYDRATION via an ambulatory/day-assessment unit or admission, whereas milder cases tolerating some fluids can be managed in the community with oral antiemetics and review — do not leave a woman who cannot tolerate fluids to "try ginger and crackers". Prescribe SAFE antiemetics in pregnancy (cyclizine, promethazine, prochlorperazine or chlorpromazine first-line, non-oral if tablets are not kept down; second line ondansetron, whose use RCOG 2024 says should not be discouraged if first line fails (MHRA January 2020: very small increase in absolute oral-cleft risk with first-trimester use), or metoclopramide limited to 5 days (MHRA August 2013)), give THIAMINE to prevent Wernicke’s encephalopathy (RCOG: oral 100 mg three times daily or IV vitamin B complex for all women admitted with vomiting or severely reduced intake), consider LMWH if admitted (RCOG GTG 37a), and replace electrolytes. Ask about mood and offer support (RCOG 2024). Consider and exclude other causes/complications: UTI, MOLAR or MULTIPLE pregnancy (ultrasound), THYROID dysfunction, and other abdominal pathology, alongside complications such as electrolyte disturbance, AKI and Wernicke’s. The hidden agenda is fear for the baby and feeling dismissed; validate that this is recognised and treatable, assess severity, arrange correct disposition (IV fluids if not tolerating oral), prescribe safe antiemetics and thiamine, exclude mimics, and follow up compassionately.