Asthma in pregnancy — structured SAQ (15 marks)

(a) Severity and chronic failure (2 marks)

One mark each.[8]

• Acute severe asthma exacerbation. She meets acute severe criteria: peak flow 58% of best (in the 33-50% range is life-threatening; she is borderline but with SpO2 under 92% she crosses into the severe-to-life-threatening zone). RR over 25 is borderline acute severe.
• Chronic management failure: she is on no inhaled corticosteroid (ICS) — she stopped it in the first trimester. This is the single largest preventable cause of exacerbation in pregnancy (Robijn 2019).[4]

(b) Immediate inpatient management (5 marks)

One mark per named intervention with drug, dose and rationale.[6][8]

• Admit to a monitored bed; alert anaesthetics and obstetric consultant. Set continuous SpO2 and cardiac monitoring; ABG if any life-threatening feature develops.
• High-flow oxygen to target SpO2 94-98% — slightly higher than non-pregnant, because the fetus needs maternal PaO2 over 70 mmHg.
• Nebulised salbutamol 5 mg oxygen-driven, repeated every 15-20 minutes (or continuous in severe). Add nebulised ipratropium 500 micrograms every 6 hours for severe or poorly responsive exacerbations.
• Systemic corticosteroid: prednisolone 40-50 mg orally (or hydrocortisone 100 mg IV if vomiting or severe). Steroids are disease-modifying; give them early, do not wait for bronchodilator failure.
• Continuous CTG in any acute exacerbation at a viable gestation — fetal compromise is a late sign; do not be reassured by a reactive trace.[6][8]

(c) Chronic stepwise plan going forward (4 marks)

One mark per element.[5][6]

• Restart ICS immediately as the foundation of chronic therapy — budesonide 400 micrograms/day is the preferred low-medium dose (most pregnancy safety data).
• Apply the BTS/NICE/SIGN stepwise ladder: Step 2 low-dose ICS plus SABA prn; Step 3 ICS plus LABA (consider the MART regimen with budesonide-formoterol); Step 4 medium/high-dose ICS plus LABA plus LTRA (montelukast 10 mg nocte); Step 5 refer specialist, add-on tiotropium/biologic/oral prednisolone.
• Start at Step 2-3 (budesonide-formoterol 200/6, 1-2 inhalations BD), with a written asthma action plan, peak flow self-monitoring, and a 1-2 week review.
• Address triggers: smoking cessation, treat any rhinitis, viral infection prophylaxis (annual influenza vaccine at any gestation; pneumococcal vaccine if not previously vaccinated).
• Refer to a respiratory physician if she fails to achieve control on Step 4, or for any severe exacerbation in pregnancy.[5][6]

(d) ICS safety counselling (4 marks)

One mark per element, with communication domain scored.[2][4]

• Sit at her eye level, use her name, acknowledge the fear: "I can see this is frightening — let me explain what the medicines do."
• The fetus is harmed by uncontrolled asthma, not by the ICS. Murphy 2013 BJOG meta-analysis: maternal asthma increases neonatal death (RR 1.49) and neonatal hospitalisation (RR 1.50). The risk is driven by maternal hypoxaemia and inflammation, not the medication.
• Inhaled corticosteroids are not teratogenic. Budesonide has the largest pregnancy safety dataset and is the preferred agent; the Davis 2025 review confirms most classes of asthma medication are reassuring in pregnancy.
• Stopping ICS in pregnancy is the largest single preventable cause of exacerbation (Robijn 2019). Continuing the ICS at the lowest effective dose is the safest choice for the baby. We will write a clear plan together; you can message me if symptoms change.[2][4]