What is the recommended treatment for carpal tunnel syndrome (CTS) in pregnancy?

Treatment of Carpal Tunnel Syndrome in Pregnancy

Conservative management is the first-line treatment for carpal tunnel syndrome during pregnancy, with surgery reserved only for severe cases with specific indicators of treatment failure.

Initial Conservative Management

Non-Pharmacological Approaches

• Wrist splinting/orthoses: First-line treatment, particularly at night
  • Most effective when worn consistently during sleep
  • Should position the wrist in neutral position (not flexed or extended)
• Activity modification:
  • Avoid repetitive wrist movements
  • Take frequent breaks during hand-intensive activities
  • Maintain neutral wrist position during daily activities
• Heat therapy: Apply warm compresses to the affected area for 15-20 minutes, 3-4 times daily 1

Pharmacological Management

• Acetaminophen: First-line medication for pain relief
  • Dosage: 500-1000mg every 6 hours as needed (maximum 4000mg/24 hours) 1
• NSAIDs should be avoided, particularly in first and third trimesters due to:
  • Increased risk of miscarriage
  • Risk of premature closure of the ductus arteriosus 1
• Corticosteroid injections: Should be used with extreme caution during pregnancy
  • Consider only when symptoms are severe and unresponsive to other treatments 1
  • Local steroid injection may be effective in some cases prior to delivery 2
• Muscle relaxants: Should be avoided unless benefits clearly outweigh risks 1

Monitoring and Follow-up

• Regular assessment of symptom progression is essential
• Monitor for:
  • Worsening paresthesias (numbness, tingling)
  • Progressive weakness of thumb abduction
  • Deterioration in two-point discrimination (>6mm is concerning) 3
  • Positive Phalen test occurring in less than 30 seconds 3

Prognosis and Natural History

• CTS in pregnancy is generally self-limiting:
  • 51% of women become symptom-free within 3 years postpartum 2
  • However, 49% continue to have some symptoms even 3 years after delivery 2
• Electrophysiological abnormalities may persist longer than symptoms:
  • Median nerve conduction remains delayed in 84% of women one year after delivery 2
  • Complete normalization of nerve conduction may take 6-20 months postpartum 4

Indications for Surgical Management

Surgery should be considered when:

1. Symptoms began during first or second trimester AND
2. Positive Phalen test occurs in less than 30 seconds AND
3. Abnormal two-point discrimination at fingertips (>6mm) 3

OR

• When conservative measures have clearly failed and symptoms are severe enough to significantly impact quality of life 5

Multidisciplinary Approach

Early diagnosis and personalized treatment require coordination between:

• Obstetricians
• Hand surgeons
• Rehabilitation physicians
• Physical/occupational therapists 6

Common Pitfalls to Avoid

1. Underdiagnosis: CTS is often mistaken for normal pregnancy-related discomfort
2. Delayed treatment: Can lead to permanent nerve damage affecting quality of life
3. Overtreatment: Most cases resolve spontaneously postpartum or with conservative treatment
4. Inappropriate medication use: NSAIDs should be avoided during pregnancy
5. Failure to recognize surgical candidates: Some patients with specific indicators will ultimately require surgery despite conservative management

CTS affects approximately 0.34% of pregnancies, with symptoms most commonly diagnosed in the third trimester, though onset can occur in any trimester 5. With appropriate management, most women will experience significant improvement without surgical intervention.