What is the most likely reason for the improvement in symptoms of a pregnant client with organ dysfunction, visual changes, hyperreflexia, and severe headache?

Symptom Resolution in Preeclampsia with Severe Features

The most likely reason for symptom improvement is lateral positioning during sleep, which relieves aortocaval compression and improves maternal hemodynamics and uteroplacental perfusion. 1

Clinical Context

This patient presented with classic signs of severe preeclampsia with neurological involvement:

• Visual changes (indicating occipital lobe involvement) 2
• Hyperreflexia (3+ deep tendon reflexes) 1, 2
• Severe headache (neurological dysfunction) 1, 3
• Organ dysfunction 1

These findings represent severe disease with cerebrovascular involvement, likely representing posterior reversible encephalopathy syndrome (PRES) or impending eclampsia. 2, 3

Why Lateral Positioning Works

Lateral positioning, especially beyond 20 weeks' gestation, is a simple but critical intervention that provides multiple physiologic benefits: 1

• Relieves aortocaval compression by the gravid uterus, which in supine position can severely compromise venous return and cardiac output 1
• Improves maternal blood flow and oxygenation through enhanced respiratory function 1
• Enhances uteroplacental perfusion by optimizing maternal hemodynamics 1
• Prevents severe hemodynamic decompensation that can occur even with brief supine positioning in critically ill pregnant patients 1

The resolution of symptoms after implementing lateral positioning strongly suggests that the patient's severe manifestations were exacerbated by positional aortocaval compression, and relief of this compression allowed for improved cerebral perfusion and resolution of neurological symptoms. 1

Why Other Options Are Incorrect

Water consumption (8 ounces/day): This amount is grossly inadequate for any pregnant patient and would not explain symptom improvement. In fact, women with severe preeclampsia often require strict fluid restriction to 60-80 mL/hour to prevent worsening cerebral and pulmonary edema. 4, 2 Increased fluid intake would potentially worsen, not improve, symptoms.

Bright lighting exposure: There is no evidence that lighting exposure affects preeclampsia symptoms or outcomes. [1-5]

Ambulation every 30 minutes: While mobility is generally beneficial in pregnancy, frequent ambulation would not specifically address the pathophysiology of severe preeclampsia with neurological symptoms. Moreover, patients with severe features often require bed rest and close monitoring rather than frequent ambulation. 1

Critical Management Considerations

This patient requires urgent evaluation despite symptom resolution: 1

• Preeclampsia with severe neurological features (visual changes, hyperreflexia, severe headache) indicates high risk for eclamptic seizures 2, 5
• Magnesium sulfate prophylaxis is mandatory for patients with preeclampsia presenting with neurological signs or symptoms 1, 2
• Standard regimen: 4 g IV loading dose, then 1 g/hour maintenance for 24 hours postpartum 2
• Delivery should be considered if at ≥37 weeks or if severe features persist despite treatment 1, 2

Monitoring requirements include: 1, 4

• Blood pressure monitoring (target systolic 110-140 mmHg, diastolic 85 mmHg) 1
• Twice-weekly laboratory tests (hemoglobin, platelets, liver and renal function) 1
• Assessment for clonus and progressive symptoms 1
• Fetal surveillance if pregnancy continues 1

Common Pitfall

Do not be falsely reassured by symptom resolution. 6 Preeclampsia can progress rapidly, and patients with prior severe neurological symptoms remain at high risk for eclampsia even if symptoms temporarily improve. 2, 6, 5 Over half of women who develop postpartum eclampsia had no diagnosis of preeclampsia during pregnancy, and symptoms can recur suddenly. 6