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. 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. She is close to life-threatening — I will treat her as acute severe with a low threshold for escalation."
• "I will run the bundle in parallel. High-flow oxygen to target SpO2 94-98% — pregnant women need slightly higher oxygenation than non-pregnant because the fetus depends on maternal PaO2. 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."
• "I will alert anaesthetics and the obstetric consultant. Continuous CTG — fetal compromise is a late sign, but I want to know the baseline. If she does not respond in 15-30 minutes, or if she develops a silent chest, cyanosis, exhaustion or a rising PaCO2, I will intubate early — 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. Normal pregnancy hyperventilates by progesterone, so the PaCO2 should be 28-32 mmHg. A PaCO2 of 42 in a pregnant asthmatic means she is exhausted and no longer compensating for her hypoxaemia. The threshold for 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, ideally the MART regimen with budesonide-formoterol 200/6, 1-2 inhalations BD."
• "I will give her a written asthma action plan, a peak flow meter for self-monitoring, and book a respiratory review within 1-2 weeks. Annual influenza and pneumococcal vaccines. Smoking cessation if relevant."
• "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, 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 research is clear on this now: inhaled corticosteroids are not teratogenic — they do not harm the baby. The harm comes from uncontrolled asthma, which starves the baby of oxygen. The largest single preventable cause of asthma attacks in pregnancy is the inhaler that was stopped — that is why we will restart it now and keep you on it through the rest of the pregnancy and breastfeeding."
• "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]

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 contraindicated in asthma — it is a prostaglandin F2alpha analogue, a potent bronchoconstrictor, and it has killed asthmatic women in PPH."
• "The safer uterotonics are oxytocin (further bolus and infusion), ergometrine cautiously if blood pressure is normal, misoprostol 800 micrograms rectally, and tranexamic acid 1 g IV over 10 minutes. I will also activate the major-haemorrhage protocol."[8]