PUQE-24 morning sickness severity score
Scores morning sickness using the three-question PUQE-24 index reproduced in RCOG Green-top Guideline 69: hours of nausea, vomiting episodes and retching episodes over the last 24 hours, for a total between 3 and 15. It bands the result as mild, moderate or severe and flags the RCOG triggers for hospital review.
PUQE-24 morning sickness severity score
No sign-up · PrivateAsked alongside the score on the RCOG form. It does not add to the total.
0 is the worst possible; 10 is the best you felt before pregnancy. Also on the RCOG form, also not part of the total.
RCOG lists weight loss greater than 5% of body weight, despite oral antiemetics, as one trigger for considering inpatient care.
Answer all three PUQE questions. The score is the sum of the three, so a partial answer cannot be scored.
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How this is calculated
FormulaThe three questions
Reproduced from Appendix II of RCOG Green-top Guideline No. 69.
In the last 24 hours, for how long have you felt nauseated or sick to your stomach? Not at all scores 1. One hour or less scores 2. Two to three hours scores 3. Four to six hours scores 4. More than six hours scores 5.
In the last 24 hours have you vomited or thrown up? I did not throw up scores 1. One to two times scores 2. Three to four times scores 3. Five to six times scores 4. Seven or more times scores 5.
In the last 24 hours how many times have you had retching or dry heaves without bringing anything up? No times scores 1. One to two times scores 2. Three to four times scores 3. Five to six times scores 4. Seven or more times scores 5.
The total and the bands
The score is the sum of the three answers, so it runs from 3 to 15, not from 0. RCOG gives the bands as: mild, 6 or less; moderate, 7 to 12; severe, 13 to 15.
The two questions asked alongside it
The same RCOG appendix asks how many hours you have slept out of 24, and asks you to rate your wellbeing on a scale of 0 to 10, where 0 is the worst possible and 10 is the best you felt before pregnancy. Neither contributes to the total. Both are recorded because they capture what the three-question score cannot.
What RCOG attaches to the number
RCOG grade C recommendation: an objective and validated index of nausea and vomiting such as the PUQE score can be used to classify the severity of nausea and vomiting of pregnancy. Women with mild symptoms should be managed in the community with antiemetics. Ambulatory daycare management should be used for suitable patients when community or primary care measures have failed and where the PUQE score is less than 13. RCOG also notes that the score can be used to track progress with treatment.
Triggers for considering inpatient care
RCOG lists inpatient management as something to consider if there is at least one of: continued nausea and vomiting with an inability to keep down oral antiemetics; continued nausea and vomiting with ketonuria and/or weight loss greater than 5 per cent of body weight, despite oral antiemetics; or confirmed or suspected comorbidity, such as a urinary tract infection with an inability to tolerate oral antibiotics.
Where the index came from
PUQE was developed by the Motherisk Program, a nausea and vomiting of pregnancy helpline in Canada, as a shorter disease-specific alternative to the Rhodes Index, and correlated highly with it. It was subsequently modified to cover the previous 24 hours, including a wellbeing score that correlated with hydration status, and later over longer periods.
A number for something nobody takes seriously enough
Nausea in pregnancy is the symptom most likely to be waved away. It has a diminutive name — morning sickness — that is wrong twice over, since it is rarely confined to mornings and it is not sickness in the sense people mean. Women are told it is normal, that it means the pregnancy is going well, and that ginger biscuits help. Some of them are unable to work, unable to keep water down, and losing weight.
The PUQE-24 index is three questions and produces a number between 3 and 15. Its value is not diagnostic. It is translational: it turns "I feel awful" into something a clinician recognises and can act on, and it is the same number they would calculate themselves.
The three questions
How many hours in the last 24 have you felt nauseated. How many times have you vomited. How many times have you retched without bringing anything up. Each is scored 1 to 5. That is the whole index.
Retching is the question people are surprised to be asked, and it is there for a good reason. Dry heaving is exhausting, it is painful, and it is entirely invisible to anyone counting how many times you were actually sick. A woman retching seven times a day and vomiting twice is having a worse day than the numbers alone suggest, and the index catches that.
Why the lowest possible score is 3
Every question has a no-symptoms option worth one point, so a woman with no nausea at all scores 3 out of 15. This catches people out and makes their score look higher than it is.
It matters for reading the bands. Mild is 6 or less, which on a scale starting at 3 is a narrow band. Moderate is 7 to 12. Severe is 13 to 15.
Thirteen is a real line
Most scoring systems produce labels. This one produces a service decision. RCOG says ambulatory daycare management should be used for suitable patients where community measures have failed and the PUQE score is less than 13.
Ambulatory daycare means going in, having intravenous fluids and treatment, and coming home the same day rather than being admitted. It is a good option and it is under-used. A score of 13 or above sits beyond the point at which daycare alone is considered enough, which is why the calculator says to make contact today rather than to keep a diary.
Treatment is the baseline, not the last resort
Read the RCOG recommendation for mild symptoms carefully: women with mild nausea and vomiting should be managed in the community with antiemetics. Anti-sickness medicine is the starting point even at the mild end, not something reserved for women who have failed at ginger.
This is worth pushing on. Anti-sickness medicines used in pregnancy have decades of safety data behind them, and the risk of untreated severe vomiting — dehydration, weight loss, electrolyte disturbance, and for some women a pregnancy they cannot enjoy or function through — is real. If you are scoring in the moderate or severe band and have been told to wait it out, a score written down with a date is a good way to reopen the conversation.
Hyperemesis is not just worse morning sickness
It is a distinct condition, and it is a recognised reason for hospital admission. RCOG lists the triggers for considering inpatient care: continued nausea and vomiting with an inability to keep down oral antiemetics; continued symptoms with ketones in the urine or weight loss over five per cent of body weight despite oral treatment; or a suspected comorbidity such as a urine infection that you cannot keep antibiotics down for.
Those triggers apply regardless of the score. This calculator asks about them separately for that reason.
The two questions that are not scored
The RCOG form also asks how many hours you slept out of 24, and asks for a wellbeing rating from 0 to 10 where 10 is how you felt before pregnancy. Neither counts towards the total, and both are worth answering.
A woman scoring 8 who rates her wellbeing at 2 and slept three hours is describing something the three-question total flattens out. Take both numbers with you.
Track it, do not just take it once
RCOG notes the score can be used to track progress with treatment, and that is where most of its practical value sits. Score yourself before a new medicine and again three days later, and you have evidence about whether it is working — which is much harder to establish from memory when every day feels the same.
One more thing worth planning for: RCOG records reported recurrence rates in a later pregnancy ranging from about 15 per cent in a hospital registry study to as high as 81 per cent where the diagnosis was self-reported. If you have had hyperemesis before, that is a reason to have the conversation with your GP or midwife early in a next pregnancy rather than waiting to see.
If you cannot keep fluids down
Do not wait for a score. Contact your maternity unit, GP or out-of-hours service today if you cannot keep any fluid down for more than a few hours, if you are passing very little or very dark urine, if you have lost more than five per cent of your body weight, if you cannot keep anti-sickness medicine down, or if you have tummy pain, a high temperature or pain on weeing.
This score classifies severity from three questions. It does not diagnose hyperemesis gravidarum, cannot rule out other causes of vomiting, and does not replace assessment by a clinician.
Sources
- The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) — Royal College of Obstetricians and Gynaecologists, accessed
- Green-top Guideline No. 69 (full text, including the PUQE-24 score in Appendix II) — Royal College of Obstetricians and Gynaecologists, accessed
- Usability of the Pregnancy-Unique Quantification of Emesis questionnaire in women hospitalised for hyperemesis gravidarum — BMJ Open (PMC), accessed
- Severe vomiting in pregnancy — NHS, accessed
- Antenatal care (NG201): Recommendations — NICE, accessed