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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 - treatment, symptoms, causes, diagnosis

Carpal - this word comes from the Greek Karpos, which means "wrist". The wrist is surrounded by bundles of fibrous tissue, which normally performs a supporting function for the joint. The confined space between these fibrous bands of fibrous tissue and the bony structures of the wrist is called the carpal tunnel. The median nerve, which runs through the wrist, provides sensation to the thumb, index, and middle fingers. Any condition that causes swelling or repositioning of tissues in the wrist can compress and irritate the median nerve. Irritation of the median nerve, in such cases, results in tingling and numbness of the thumb, index, and middle fingers, a condition known as "carpal tunnel syndrome."

Causes of Carpal Tunnel Syndrome

Given the limited space of the carpal tunnel, any swelling in this area can put pressure on the median nerve, causing the symptoms of carpal tunnel syndrome. There are many different causes leading to the development of this syndrome, but often the exact cause cannot be determined. Some people initially have an anatomically narrower carpal tunnel, which makes them more at risk of developing carpal tunnel syndrome. It is believed that this tendency can be genetically determined, and if there are cases of this syndrome in the family, then the likelihood of pressure on the median nerve increases significantly. You are also more likely to develop carpal tunnel syndrome if you are overweight, smoke, or drink too much alcohol. The same risk factor is age - the older the person, the higher the likelihood of developing carpal tunnel syndrome. Women are more prone to this syndrome than men due to the narrower carpal tunnel. There is also a greater tendency to develop carpal tunnel syndrome if there was a wrist injury (rupture or sprain) or there are diseases such as:

• diabetes mellitus
• osteoarthritis
• rheumatoid arthritis
• hypothyroidism

It is possible that hormones play a role in the development of carpal tunnel syndrome, as some women develop the syndrome during pregnancy or menopause. Hormones produced during pregnancy can lead to fluid retention, which in turn can cause swelling in the wrist. It is noted that the performance of certain activities can lead to the development of this syndrome. People who do a lot of heavy manual work or repetitive wrist movements, such as on an assembly line or working with their hands in cold temperatures, are also at greater risk of developing carpal tunnel syndrome. But the probability increases significantly if the load is combined with the presence of systemic diseases.

Symptoms of carpal tunnel syndrome

Patients with carpal tunnel syndrome initially feel numbness and tingling in the hand along the median nerve innervation (thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and may even lead to awakening from sleep. The reason for the worsening of symptoms at night may be due to the flexed position of the wrist during sleep and / or the accumulation of fluid around the wrist and hand while it is in a horizontal position. Carpal tunnel syndrome may be a temporary condition that resolves completely on its own, or symptoms may persist and progress.

As the syndrome progresses, patients may develop a burning sensation and/or spasms and hand weakness. Decreased grip strength can cause objects to fall out of the hand frequently. Sometimes sharp shooting pains can also be felt in the forearm. Chronic carpal tunnel syndrome can also lead to muscle atrophy in the hand, especially the muscles at the base of the thumb on the palmar surface.

Diagnosis

Carpal tunnel syndrome can be diagnosed based on the symptoms and characteristic areas of numbness in the hand. But at the same time, it is often necessary to exclude other possible causes of symptoms that mimic carpal tunnel syndrome. It could be neck, shoulder or elbow problems. The doctor examines the wrist to detect swelling, local temperature increase, tenderness, and discoloration. Sometimes pressing on the front of the wrist can produce a tingling sensation in the hand and is called the Tinel sign, which is characteristic of carpal tunnel syndrome. Symptoms can also be reproduced from time to time with forward flexion of the wrist (called the Phalen symptom). The final diagnosis can be made with ENMG. As a rule, with carpal tunnel syndrome, there is a slowdown in the conduction of a nerve impulse after the nerve passes through the wrist.

Testing of limb muscles, an electromyogram, is sometimes done to rule out or detect other conditions that may mimic carpal tunnel syndrome.

Laboratory tests may be performed in order to diagnose conditions associated with carpal tunnel. These tests include thyroid hormone testing, complete blood counts, blood sugar levels, etc. An x-ray of the hand may also be ordered to check for bony changes (abnormalities in the bones and joints of the wrist). MRI is necessary in cases where it is necessary to visualize changes in ligaments, cartilage.

Treatments for carpal tunnel syndrome

The choice of treatment for carpal tunnel syndrome depends on the severity of the symptoms and the underlying disease that may be causing the symptoms.

In the first stage, treatment usually includes rest, immobilization of the wrist in a brace, and sometimes local cold. If the patient's profession is associated with a load on the wrist, then it is necessary to change activities for a while. In addition, it is possible to improve the ergonomics of the workplace, for example, you can adjust the computer keyboard and chair height and optimize the load on the hands. These measures, along with occasional periods of rest and wrist stretching, can actually prevent the symptoms of carpal tunnel syndrome, which are caused by repetitive excessive motion of the wrist, from developing. If there are systemic diseases or injuries, then individual treatment of these diseases is carried out. In case of fractures, orthopedic correction (gypsum, orthosis) may be required. Overweight patients should be advised to reduce weight. In rheumatoid arthritis, specific treatment of the inflammatory autoimmune process is carried out. Swelling of the wrist, which may be associated with pregnancy, disappears after the birth of the child.

Medications

Several types of medications can be used to treat carpal tunnel syndrome. Vitamin B6 (pyridoxine) is often prescribed in the treatment of carpal tunnel syndrome, and although the mechanism of therapeutic action is not entirely clear, nevertheless, many doctors note a certain effect of using this drug. Non-steroidal anti-inflammatory drugs may also be helpful in reducing inflammation and reducing pain. But these drugs have side effects and therefore it is necessary to take this into account when prescribing them. Corticosteroids may also be used. They can be given orally or by injection into the affected wrist joint. Corticosteroids can lead to a rapid improvement in symptoms, but the side effects of these drugs prevent their use for a long time and in the presence of certain conditions (for example, in diabetes mellitus, their use may lead to a worsening of the condition). They should also not be used in the presence of infections. In addition to drug treatment, physiotherapy and acupuncture also provide a certain therapeutic effect. Most patients with carpal tunnel syndrome can be treated with conservative therapy. But sometimes chronic pressure on the median nerve can lead to permanent numbness and weakness. In order to avoid serious and permanent nerve and muscle damage, surgical treatment may be recommended in such cases. Surgical intervention consists in excising the tissue that puts pressure on the median nerve. This surgical procedure is called carpal tunnel release. Currently, such an operation can be performed using endoscopic techniques, which allows for minimal tissue trauma and rapid restoration of nerve conduction. After surgical treatment, it is necessary to use exercise therapy to restore hand function.

Prognosis of carpal tunnel syndrome

Complications of carpal tunnel syndrome are rare and include atrophy and weakness of the muscles at the base of the thumb in the palm of the hand. This can become a permanent disorder if not treated on time. Such atrophy disrupts the motor skills of the hand and the performance of certain movements. As a rule, the prognosis for carpal tunnel syndrome is positive and it is possible to cure it conservatively or surgically.

carpal tunnel syndrome of the carpus

Carpal tunnel syndrome is a condition where there is compression 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 the 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

• Feeling of numbness of the fingers. 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.

• Paresthesias . 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 agility 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. Pain and paresthesia occur when the wrist is maximally flexed for a minute or less.
• 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 upward and held in this position for a 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: The carpal ligament is dissected through an incision (5mm) in the area of ​​the carpal canal.

• 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.

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