Severe asthma at 30 weeks — structured oral station (12 minutes)

Opening prompt — "Talk me through your assessment and immediate plan."

Model response — say it in this order:^[8]

• "This is acute severe asthma in pregnancy with a life-threatening feature. She meets the criteria: peak flow 240 is 50% of her best, RR 28, HR 110, she cannot complete sentences in one breath, SpO2 90% on room air — under 92% is life-threatening. I will manage her as acute severe with life-threatening features and a low threshold for escalation."
• "I will run the bundle in parallel. High-flow oxygen to target SpO2 94-98% — to prevent maternal and fetal hypoxia. Oxygen-driven nebulised salbutamol 5 mg, repeated every 15-20 minutes; nebulised ipratropium 500 micrograms. Prednisolone 40-50 mg orally — or hydrocortisone 100 mg IV if she cannot swallow. Steroids are disease-modifying; give them up front."^[8]
• "I will alert anaesthetics and the obstetric consultant. Continuous CTG — she is severe, so fetal monitoring runs alongside resuscitation. If she does not respond in 15-30 minutes, or if she develops a silent chest, cyanosis, exhaustion or a rising PaCO2, I will keep a low threshold for intubation — pregnancy decompensates fast."
• "The underlying cause is the inhaled corticosteroid she stopped at the booking visit. After the acute episode, I will restart her on the BTS/NICE/SIGN stepwise ladder."^[6]

Examiner is listening for: severity recognition, the acute bundle with doses, the SpO2 target, the early-escalation principle, and the ICS-cessation cause.^[6]

Probe 1 — "Her PaCO2 comes back at 42 mmHg. What does that mean?"

• "This is the PaCO2 trap. Progesterone-driven hyperventilation keeps her baseline PaCO2 well below non-pregnant ranges — a value of 42 means she has lost that compensation and is tiring. The threshold for escalation and intubation in pregnancy is lower than in the non-pregnant patient. I will call anaesthetics now and prepare for intubation if she does not turn around within the next 15-30 minutes."^[8]

Probe 2 — "She improves after one round of the bundle. How do you restart her chronic therapy?"

• "She will need a step-up from where she was. Before she stopped her beclometasone, she was on Step 2 — I will restart at Step 3 because of this severe exacerbation: low-dose ICS plus LABA, considering the MART regimen with ICS-formoterol per local formulary."
• "I will give her a written asthma action plan, a peak flow meter for self-monitoring, GP/asthma-nurse review within 2 working days and respiratory follow-up within 4 weeks. Inactivated influenza vaccine; assess pneumococcal status per local guidance. Smoking cessation if relevant."^[5]
• "If she fails to achieve control on Step 4 (medium-dose ICS plus LABA plus LTRA), I will refer to a respiratory physician for Step 5 add-on therapy — tiotropium, a biologic such as omalizumab or mepolizumab (pregnancy data limited, so a specialist decision), or oral prednisolone."^[5][6]

Probe 3 — "She is upset and asks whether her decision to stop the inhaler has harmed the baby."

This is a scored communication domain. Demonstrate it out loud:^[4]

• Sit at her eye level, use her name, acknowledge the fear: "I can see this is frightening — let me explain what we know."
• "Your decision was made with the best intentions, in conversation with your GP, to protect the baby. You did not know. The good news is that the baby's heart rate has been steady throughout, and we have caught this early."
• "The evidence now supports continuing ICS as normal in pregnancy — the harm comes from uncontrolled asthma, which starves the baby of oxygen. Stopping the inhaler is a major preventable cause of attacks — that is why we will restart it now and keep you on it through the rest of the pregnancy."
• "I am not going to dwell on what happened. We are going to focus on the plan we make together — and you can call me anytime if symptoms change."^[4][6]

Probe 4 — "She delivers vaginally at 39 weeks and has a significant postpartum haemorrhage from uterine atony. The midwife draws up carboprost. What do you do?"

• "Stop her. Carboprost is a prostaglandin F2alpha that can provoke bronchospasm — use it with extreme caution or avoid it in asthma, where it is associated with exacerbation."
• "The safer path is oxytocin (further bolus and infusion), ergometrine if blood pressure is normal, and misoprostol or tranexamic acid per the local PPH protocol. I will also activate the major-haemorrhage protocol."^[15]