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Carpal tunnel syndrome and pregnancy go hand in hand | Your Pregnancy Matters

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MedBlog

Your Pregnancy Matters

October 20, 2020

Your Pregnancy Matters

Robyn Horsager-Boehrer, M. D. Obstetrics and Gynecology

Swelling – everywhere – is one of the most common symptoms of pregnancy. Patients often notice extra puffiness in their face, legs, and feet. But for some women, swelling manifests inside the wrist, resulting in carpal tunnel syndrome (CTS).

Approximately 4% of adults in the general population have carpal tunnel syndrome, but 31% to 62% of pregnant patients have it. Many patients notice symptoms after 30 weeks' gestation.

During pregnancy, your blood volume doubles. That extra fluid increases pressure and swelling in the blood vessels throughout your body. In tight spaces such as the carpal tunnel area of the wrist – through which nine tendons and one nerve pass – the swelling can compress the median nerve, which runs to the hand.

The median nerve gives sensation to the palm-side surface of thumb, index, and middle fingers, and half the ring finger. It's also responsible for helping to move the muscles in the hand that bend your fingers.

Nerve compression can cause pain, tingling, and numbness in the wrist and hand, which may increase when you're trying to sleep. Pregnancy may be the first time CTS symptoms arise or the last straw that causes a woman to see her doctor for ongoing symptoms.

The good news is that pregnancy-safe treatment is available, and symptoms typically subside for many patients after the baby arrives.

I've invited my colleague, Rupali Kumar, M.D., from UT Southwestern's Physical Medicine and Rehabilitation (PM&R) team to discuss CTS symptoms and treatment options.

Carpal tunnel symptoms in pregnancy

When the median nerve is compressed during pregnancy, symptoms present as they would in any patient:

● Numbness and tingling

● Burning sensation

● Pain in the wrist or hand

At the onset of CTS, symptoms may come and go. But when numbness or weakness occurs frequently or constantly, that's a potential sign of nerve damage.

In severe cases, patients may have weakened grip strength or decreased finger dexterity. For example, you might have trouble picking up small objects with your fingers, opening jars, or buttoning clothes.

Related reading: 5 weird pregnancy symptoms you might not know about

Diagnosing carpal tunnel in pregnancy

We often can diagnose CTS by talking with you about your symptoms and medical history. If your symptoms are severe, we may recommend an electrodiagnostic study (EMG) to confirm the diagnosis and measure nerve function in the arm, wrist, and hand. An EMG can tell us whether you have nerve damage, how severe it is, and whether it might be reversible with intervention.

The doctor will attach small electrode stickers to your hand and arm in different places and apply low levels of electrical stimulation to gauge the nerve activity. The doctor may also insert a fine acupuncture-like needle in certain areas of the arm and hand to test muscle electrical activity. The study can be a little uncomfortable, but should not cause lasting pain.

Pregnancy-safe treatment options

With CTS, it's best to start with the most conservative therapies. That's especially true in pregnancy. Here is a list of carpal tunnel treatment options that are safe for pregnancy, from least to most invasive.

Splinting

The first-line treatment is to immobilize the wrist in a neutral position to limit the range of flexion or extension. We use a neutral wrist splint with a metal bar inside that prevents the wrist from moving up, down, or side-to-side but allows the fingers to move.

Splinting gives the median nerve a break and can help alleviate swelling, which can allow mild to moderate nerve damage to heal. However, it's tough to wear a splint all day and do everyday activities. Your doctor may recommend wearing it while sleeping and as much as you can during the day.

Occupational therapy

Hand and wrist therapy can sometimes help relieve symptoms and prevent further nerve damage. A PM&R doctor or occupational therapist can create a personalized plan for you.

Therapy may include wrist and finger range of motion and strengthening movements, massage, and nerve gliding techniques. We may also recommend desensitization to decrease nerve pain, including alternating hot and cold water baths.

Medication

Topical numbing agents can relieve symptoms, but these ointments won't get to the root of the problem. Some patients may benefit from pain relief injections, which include a combination of steroids and a local anesthetic injected around the median nerve under ultrasound guidance.

However, if there are other therapies to try, we typically avoid prescribing steroids during pregnancy to avoid side effects.

Check with your Ob/Gyn before using any over-the-counter or prescribed topical medications. Our PM&R doctors will consult with your Ob/Gyn prior to recommending medication during pregnancy.

Surgery, in severe cases

Carpal tunnel release surgery is reserved for severe cases. In this procedure, a surgeon will cut the ligament that presses on the carpal tunnel, making more room for the median nerve and tendons. This usually improves function and pain.

Generally, we recommend waiting until after pregnancy to have surgeries that are not urgent. If wrist pain or hand weakness severely limits your daily function, talk with your Ob/Gyn about the risks and benefits of having carpal tunnel surgery prior to delivery.

When will symptoms improve?

After delivery, your fluid levels and the extra pressure in your blood vessels will decrease. As such, your symptoms will likely improve or resolve.

That being said, new mothers use their hands and wrists nearly constantly. Lifting, changing, and feeding the new baby may lead to worsened or new hand and wrist symptoms.

Let your Ob/Gyn know as soon as symptoms begin. If we catch carpal tunnel early enough, we can start conservative treatments to reduce the risk of nerve damage or lingering symptoms.

After pregnancy, keep an eye on your wrist health. You'll be lifting your baby a lot and making repetitive motions, which can lead to tendinopathies related to overuse.

Even if your new aches and pains don't seem overtly pregnancy-related, let your Ob/Gyn know. Pregnancy does strange things to the body, and your provider can help you find relief from painful or annoying symptoms.

To visit with an Ob/Gyn, call 214-645-8300 or request an appointment online.

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carpal tunnel syndrome

Carpal tunnel syndrome is a condition where compression occurs in the carpal (carpal) canal of the median nerve. Compression or trauma can provoke it.

The concept of carpal tunnel syndrome is not universal for the wrist area, this condition can also manifest itself in other anatomical areas where the nerves lie quite superficially and close to the bone structures at the same time. The syndrome under consideration manifests itself in the form of a decrease or lack of sensitivity in the thumb, index, middle and half of the ring finger, as well as a violation of motor function in them.

Carpal tunnel syndrome is a common pathology and occurs in 1-3% of the population, and mainly in people whose occupation is associated with fine, monotonous motor skills of the hand. Half of all those suffering from this syndrome are people whose type of employment is associated with the use of a computer. Also, this disease can be considered an occupational pathology in musicians, tailors, office workers, etc. The syndrome occurs in the active working-age population at an already mature age (40-60 years), and in 105 cases even at a younger age. The researchers concluded that active PC users have a 15% higher risk of developing the syndrome, especially women.

Causes of carpal tunnel syndrome

The median nerve in the hand passes through a tunnel formed by the transverse ligament and carpal bones of the hand. To provoke compression of the nerve in the canal can:

• Traumatic injuries of the hand. Bruises, sprains, sprains, fractures can cause swelling of the ligaments and muscles, or even displacement of the bones of the wrist. All this can compress the nerve in the canal and cause a violation of its function. With proper treatment, all these processes are reversible, but if timely and correct assistance is not provided, then muscle and ligament contractures, as well as bone deformities, may already be irreversible.

• Arthrosis, arthritis and other pathological articular processes of various etiologies and genesis. Edema and inflammatory reactions caused by these pathologies, up to tissue necrosis, can also cause nerve compression. With the permanent course of inflammation and the progression of degenerative-dystrophic processes, the articular surfaces of the wrist lose their properties and wear out, resulting in deformation and compression of the nerve in the canal by already bone structures.

• Inflammation of tendons or tendovaginitis. Inflammation can be septic (caused by microorganisms) and aseptic (caused by exercise, hypothermia, etc.). Diseases such as purulent wounds of the hand, including panaritiums, improper technique for taking blood from a finger, etc., can provoke septic inflammation. Non-infectious inflammation can be caused by chronic traumatic stress, for example, frequent monotonous motor skills of the hand, static load on it, temperature injury.

• Diseases that lead to water retention in the body can cause swelling of the extremities and, as a result, lead to an increase in soft tissue volume and compression of the median nerve. Violation of the water and electrolyte composition can cause: pregnancy, taking hormonal contraceptives, menopause, kidney disease, etc.

• Rare, but tumors of nervous tissue and median nerve in particular. Most of these are benign neoplasms (schwannomas, neurofibromas, perineuromas), but there are also malignant ones arising from the nerve sheaths. With its growth, the tumor compresses the nerve, which leads to its damage.

• Diabetes mellitus. Under the influence of the protein kinase C enzyme, sorbitol and fructose accumulated in the course of the disease begin to break down in nerve tissues. Because of this, as well as because of the violation of the trophism of neurons and their processes, aseptic inflammation of the nerves and surrounding tissues occurs. Edema increases, which in turn leads to compression of the nerves, including the median one.

• Acromegaly. As a result of prolonged and intensive growth of a person suffering from acromegaly, processes of disproportionate growth of bone and soft tissues occur. The median nerve can be entrapped in a narrowed carpal tunnel due to increased bone volume and narrowing of its lumen.

• Congenital malformations . The transverse carpal ligament may be thickened from birth, and there is also poor production of tendon lubrication. One of the factors predisposing to carpal tunnel syndrome can be an anatomical feature of the structure, the so-called "square wrist".

Carpal tunnel symptoms

• Finger numbness. The syndrome under consideration, as a rule, develops gradually and, in general, the lesion manifests itself unilaterally. Basically, the pathological process occurs in the limb that is leading, for right-handers, the right hand, and for left-handers, the left hand. Carpal tunnel syndrome develops gradually. However, a bilateral process can also be observed, with diseases of the endocrine system, pregnancy, etc.

• Paresthesia . Manifested in the form of tingling sensations and loss of sensation in the fingers. Appear in the morning, after waking up and disappear within a few hours. But over time, these manifestations become more stable and intense and may already become permanent. This can lead to a violation of the normal function of the limb: strength, dexterity, etc., the patient has to change hands when performing actions, give rest to the affected limb. Particular inconvenience is caused by manipulations requiring static tension of the limb.

• Pain. When the disease manifests itself, a burning and tingling sensation may appear in the hand, which is rather quickly eliminated by lowering the limb down and shaking it. The blood flow in the arm resumes, and the pain disappears. As a rule, this happens during sleep due to the static position of the hand, or during monotonous work performed by the limb. Pain is not characteristic of any specific joints and is common. With the progression of the disease, pain can cover not only the fingers, but the entire hand and arm up to the elbow joint, which often makes it difficult to make a diagnosis. The patient cannot perform his duties because the pains may occur during the daytime.

• Loss of dexterity and strength. Over time, if the disease is not treated, the limb begins to lose strength and dexterity in movements. It is difficult for the patient to hold objects in his hands, especially small ones, as if they fall out spontaneously. The ability to perform fine motor skills is lost (grabbing small things, opposing the thumb, etc.).
  

• Reduced sensitivity. Over time, the patient may begin to notice that he does not distinguish the temperature of objects well, stops feeling touches or even injections. There is a painful burning sensation in the hand, numbness.

• Muscle atrophy. In advanced forms of the syndrome, atrophy of the musculoskeletal apparatus of the arm may develop, muscles and ligaments not only lose strength, but also decrease in size. Over time, the brush deforms and takes on a shape resembling a monkey's paw.

• Skin discoloration. Due to the fact that when the innervation of the hand is disturbed, there is also a violation of the nutrition of skin cells, a change in the color of the skin occurs, they become lighter and unevenly colored.

Diagnosis of carpal tunnel syndrome

For an accurate diagnosis, a consultation with a neurologist is necessary. In this case, the doctor conducts a number of specific tests, and laboratory and instrumental methods of research can also be used.

Tests for carpal tunnel syndrome:

• Tinel test. In the narrowest part of the carpal tunnel, on the side of the palm, when tapping, unpleasant tingling sensations occur.
• Phalen test. Wrist flexed to its maximum for a minute or less causes pain and paresthesia.
• Cuff test. Place the cuff from the blood pressure monitor on the forearm and inflate as much as possible. Within one minute, with a positive test and the presence of the syndrome, a feeling of numbness and tingling appears.
• Raised hands test. The upper limbs are lifted vertically upwards and held in this position for one minute. With a positive result, discomfort appears after 30-40 seconds.

All of the above tests can be done at home, and if you have at least one positive test, be sure to consult a doctor.

Of the instrumental research methods, the following are used:

• electroneuromyography;
• x-ray examinations;
• MRI;
• ultrasound.

To identify the causes of the disease, the patient is prescribed a blood and urine test:

• blood biochemistry;
• blood and urine test for sugar;
• thyroid-stimulating hormone test;
• clinical analysis of urine and blood;
• blood test for rheumatoid factor, C-reactive protein, antistreptolysin-O;
• blood test for circulating immune complexes;
• blood test for antistreptokinase.

Carpal tunnel treatment

The most important thing in the treatment of carpal tunnel syndrome is the observance of measures to prevent the development of the disease. Even with the best and highest quality treatment, preventive measures are indispensable, because the effect may simply not be achieved.

1. Preventive measures for carpal tunnel syndrome. When the first signs of the disease occur, it is necessary to firmly fix the hand so that there is no possibility of movement in the joint and, as a result, injury to the nerve. The fixator can be applied by a doctor or, for temporary use, purchase an elastic bandage from a pharmacy. Within two to three weeks, you should avoid activities that aggravate the symptoms of the disease. Also, to reduce swelling, it is recommended to apply cold in the wrist area for 2-3 minutes 2-3 times a day. In the subsequent period, treatment is prescribed depending on the severity of the course of the pathological process and its severity. If necessary, the treatment is based on the treatment of the underlying disease (traumatic injury, hypothyroidism, diseases of the urinary system, diabetes mellitus, etc.) that causes compression of the nerve in the canal.

2. Topical treatment. Includes the use of compresses, the introduction of medicines into the canal cavity. These procedures allow you to quickly ease the painful manifestations and relieve local inflammation.

3. Medical therapy. Drug therapy in each case is selected individually depending on the underlying or concomitant disease. In this case, B vitamins, non-steroidal anti-inflammatory drugs, vasodilators, diuretics, anticonvulsants, muscle relaxants, glucocorticosteroids, antidepressants, etc. are often prescribed.
4. Physiotherapy. Can be used both in drug therapy and in the postoperative period during rehabilitation. In this case, they apply: acupuncture; manual therapy techniques; ultraphonophoresis; shock wave therapy. Before using physiotherapy procedures, it is necessary to consult a specialist for contraindications.

Surgical treatment of carpal tunnel syndrome

If for 6 months or more conservative therapy does not give the desired effect, then it makes sense to think about the surgical resolution of the disease. The main task of surgery is to relieve pressure on the median nerve by widening the carpal tunnel.

Most operations are performed under local anesthesia. The following methods are used:

• Open access: through the incision (5mm) in the area of ​​the carpal tunnel dissect the carpal ligament.

• Endoscopic surgery. There are two types of endoscopic intervention, through two incisions and through one. In the first case, an endoscope is inserted into one incision, and the ligament is cut into the second instrument. In the second case, both instruments are inserted one hole at a time.

At the end of the surgical intervention, a plaster cast is applied to the arm to immobilize the limb. After removing the plaster, a course of physical therapy and physiotherapy is carried out. As a rule, complete restoration of the function of the hand occurs within six months. After recovery, the patient can return to work, subject to the protective regimen, so as not to provoke a relapse of the disease. In the modern world, where computer technology has already been introduced everywhere, the pathology we are considering is becoming more and more common. Timely and qualified assistance, and prevention in the event of carpal tunnel syndrome, allows you to fully and with sufficient persistence achieve remission.

Carpal tunnel syndrome in pregnancy

02/26/2020

At the end of the second trimester of pregnancy many women suffer from hand numbness. Around the 26th week there is tingling, numbness and pain in the fingers, sometimes extending to the shoulder. This is carpal tunnel syndrome, which in pregnant women is associated with hormonal changes and water retention in the body.

As a result of stagnant fluid, compression of the nerves in the wrist reaches the fingers. The symptoms are worse especially at night. The pain can be so severe that it can wake the woman up or prevent her from getting a good night's sleep. Although carpal tunnel syndrome is a problem and usually resolves spontaneously 2-3 weeks after delivery .

How to deal with hand numbness in pregnant women?

A woman with carpal tunnel syndrome should avoid positions that cause pressure on her arm. Sometimes symptoms come from shaking the numb limb or placing it below the heart line (eg on the knee) or loosely lowering the arm (also during sleep).