What is the most appropriate initial management for a 30-year-old woman at 16 weeks gestation with symptoms of carpal tunnel syndrome, including numbness and tingling of the thumb and index finger, exacerbated by tennis activities?

Management of Carpal Tunnel Syndrome in Pregnancy

The most appropriate initial step is nighttime wrist splinting in a neutral position, as carpal tunnel syndrome in pregnancy should be treated conservatively given the high likelihood of spontaneous postpartum resolution. 1

Rationale for Conservative Management in Pregnancy

Carpal tunnel syndrome is commonly exacerbated during pregnancy, and the clinical presentation described—nocturnal symptoms with numbness and tingling in the median nerve distribution (thumb and index finger), positive Phalen's test (passive wrist flexion reproducing symptoms)—is classic for this condition 2. However, pregnancy fundamentally changes the management approach:

• Pregnancy-related carpal tunnel syndrome typically resolves spontaneously after delivery, making aggressive intervention unnecessary in most cases 1
• Conservative treatment should be exhausted before considering any invasive options during pregnancy 1

Specific Initial Management Steps

Wrist Splinting Protocol

• Apply a neutral position wrist splint for nighttime use, as this is the most effective initial conservative treatment 3, 4
• Night-only splinting is as effective as continuous wear, making it more practical and better tolerated 5
• The splint should maintain the wrist at 0-5 degrees of extension (neutral to slightly extended position) 4
• Duration should be several weeks, with reassessment of symptom improvement 4

Activity Modification

• Advise temporary reduction or modification of tennis activities, as repetitive forceful wrist movements can exacerbate symptoms 6
• The patient should avoid activities that provoke symptoms during the day while continuing splint use at night 4

Why Other Options Are Not First-Line

Corticosteroid Injections

• While local corticosteroid injections can provide symptom relief and may be slightly more effective than splinting at 6 weeks, they carry theoretical risks during pregnancy and should be reserved for refractory cases 5
• Injections should not be first-line in a pregnant patient when conservative splinting has not yet been attempted 3, 1

Oral Medications

• NSAIDs and acetaminophen have not shown benefit for carpal tunnel syndrome and do not address the underlying median nerve compression 3, 5
• Oral corticosteroids, while effective for short-term management (2-4 weeks), are not preferred during pregnancy when splinting has not been tried 1

Surgical Intervention

• Surgery is absolutely contraindicated as initial management in pregnancy, given the high rate of spontaneous postpartum resolution 1
• Surgical decompression should only be considered after failed conservative management and is rarely needed during pregnancy 3

Expected Clinical Course

• Most pregnant women with carpal tunnel syndrome will experience complete resolution of symptoms after delivery 1
• If symptoms persist beyond 6-8 weeks postpartum, then more aggressive treatment including corticosteroid injection or surgical evaluation may be warranted 1
• The patient should be counseled that her symptoms are likely pregnancy-related and temporary 1

Common Pitfalls to Avoid

• Do not proceed directly to corticosteroid injection without attempting splinting first, especially in pregnancy 3
• Do not prescribe NSAIDs or acetaminophen as primary treatment, as these are ineffective for nerve compression 3, 5
• Do not recommend continued high-impact tennis without modification, as this repetitive activity will perpetuate symptoms 6