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An otherwise healthy 49 –year-old female presented at 21-weeks’ gestation with acute confusion and reduced oral intake on a background severe hyperemesis for three weeks.Clinical examination revealed she was disoriented to time, place and person. She had slow, dysarthric, tangential speech with bradyphrenia. Clinical examination revealed multidirectional gaze evoked horizontal nystagmus and mild upper limb distal postural tremor. She was unable to follow commands for gait assessment. Investigations revealed normal B12 and thyroid function, mildly low folate and albumin. Liver function tests were normal. Non-contrast MRI brain revealed bilateral symmetrical high T2 and FLAIR signal change in the mammillary bodies, medial thalami and around the periaqueductal region. These are imaging findings supportive of the diagnosis of Wernicke’s encephalopathy. She was treated with prolonged intravenous thiamine, occupational and speech therapy. She made a mild clinical improvement before discharge to rehabilitation.Wernicke’s encephalopathy is a rare severe neurological consequence of thiamine (vitamin B1) deficiency and can result from hyperemesis gravidarum.1 2 Pregnancy in itself can also drive thiamine loss.1 This case highlights a challenging diagnosis, due to subtle clinical signs and imaging findings. Timely diagnosis and adequate thiamine replacement remains critical to prevent irreversible neurological damage and adverse perinatal outcomes.1 2 References Oudman I, et al. Wernicke encephalopathy in hyperemesis gravidarum: a systematic review. Eur J Neurol. 2019.Fiorentini C, et al. Wernicke’s encephalopathy in hyperemesis gravidarum: a systematic review. Neurol Clin Neurosci. 2023.rajesh.ambati@nhs.net