Carpal Tunnel Syndrome in Pregnancy: Wrist Splinting
The best next step is splinting of the wrist in a neutral position, which is the first-line conservative treatment for carpal tunnel syndrome during pregnancy. 1, 2
Clinical Reasoning
This 35-year-old pregnant woman at 35 weeks gestation presents with classic carpal tunnel syndrome (CTS): progressive wrist/forearm pain, tingling, and decreased sensation over the median nerve distribution (first and second fingers). The absence of trauma and the timing during late pregnancy strongly suggest pregnancy-related CTS, which occurs due to fluid retention and increased joint laxity. 1, 2
Why Splinting is the Correct Answer
Wrist splinting in neutral position is the appropriate initial management because:
Carpal tunnel syndrome, particularly compartment syndromes like this, may be exacerbated by pregnancy and should be identified and treated conservatively before considering more invasive options 1
Neutral-position wrist splinting provides superior symptom relief compared to extension splinting, with most improvement occurring within the first 2 weeks of wear 3
Conservative treatment with wrist splinting is most effective in patients with minimal to moderate lesions and shorter symptom duration (less than 3 months provides better outcomes) 4, 5
The patient has only "past few weeks" of symptoms, placing her in the favorable prognostic category for conservative management 4
Why Other Options Are Incorrect
Complete blood count is not indicated as there is no clinical suggestion of infection, anemia, or hematologic disorder that would explain isolated median nerve compression symptoms.
Magnetic resonance imaging is unnecessary for straightforward CTS diagnosis, which is made clinically. MRI would not change initial management and involves unnecessary cost and time. Additionally, the diagnosis is clear from history and physical examination alone. 4
Ultrasound has no role in the initial management of carpal tunnel syndrome. While ultrasound can visualize the median nerve, it does not alter the first-line treatment approach of conservative management with splinting.
Practical Implementation
Provide a neutral-position wrist splint (0 degrees, not extended) for continuous wear, particularly at night 3, 5
The splint should be worn continuously for at least 2-3 weeks initially, as symptom relief typically does not improve significantly between 2 weeks and 2 months 3
Reassess after 2-3 weeks; if no improvement by 5 months, splinting has reached its limit of effectiveness 5
Most pregnancy-related CTS resolves spontaneously after delivery due to resolution of fluid retention 1
Important Caveats
The absence of thenar muscle wasting is favorable and supports conservative management first 4
Patients with sensory changes (as this patient has) have slightly lower success rates with conservative treatment (60% vs 90% in those without sensory changes), but splinting remains the appropriate first step 4
If symptoms persist or worsen despite splinting, or if thenar atrophy develops, electrodiagnostic studies and surgical consultation would be warranted postpartum 5
Avoid surgical intervention during pregnancy unless absolutely necessary; most cases improve after delivery 1