What is the most appropriate initial management for a 16-week pregnant woman with carpal tunnel syndrome, presenting with numbness and tingling of her thumb and index finger, and a history of type 2 diabetes mellitus (DM)?

Wrist Splinting is the Most Appropriate Initial Management

For this pregnant woman with carpal tunnel syndrome at 16 weeks gestation, wrist splinting in a neutral position should be initiated immediately as first-line treatment. This is the recommended initial approach by the American College of Obstetricians and Gynecologists and American Academy of Orthopaedic Surgeons for pregnancy-related carpal tunnel syndrome 1, 2.

Clinical Rationale

Why Splinting is Optimal

• Conservative treatment with nighttime wrist splinting is the initial management step for carpal tunnel syndrome in pregnancy, with moderate strength of evidence 1.
• Wrist splinting in a neutral position provides superior symptom relief compared to other conservative options and is most effective in patients with minimal to moderate lesions and shorter symptom duration 2, 3.
• The positive Phalen's test (passive wrist flexion eliciting symptoms) confirms the diagnosis and supports conservative management 1.
• Most pregnancy-related carpal tunnel syndrome resolves spontaneously after delivery due to resolution of fluid retention, making aggressive intervention unnecessary 2.

Why Other Options Are Inappropriate

Follow-up in 3 months is inadequate because the patient has already had 4 weeks of symptoms and requires active treatment now, not delayed observation 1.

B12 supplementation is not indicated as there is no evidence of B12 deficiency causing her symptoms; her carpal tunnel syndrome is related to pregnancy-induced fluid retention and increased joint laxity 2.

Gabapentin is contraindicated because NSAIDs and similar medications have not shown benefit for carpal tunnel syndrome and do not address the underlying median nerve compression 1. Additionally, medication safety in pregnancy must be carefully considered.

Orthopedic surgeon referral is absolutely contraindicated as initial management given the high rate of spontaneous postpartum resolution; surgery should be avoided during pregnancy unless absolutely necessary 1, 2.

Special Considerations in This Patient

Diabetes as a Risk Factor

• Type 2 diabetes increases the risk and frequency of carpal tunnel syndrome, with carpal tunnel syndrome diagnosed in 39% of diabetic patients overall and 46% of diabetic women 4.
• The main risk factor for carpal tunnel syndrome in diabetics is duration of diabetes, and to a lesser degree female gender and obesity 4.
• Her 5-year diabetes history makes her higher risk, but this does not change the initial conservative management approach 4.

Pregnancy-Specific Factors

• At 16 weeks gestation (second trimester), she has approximately 24 weeks until delivery, during which symptoms may fluctuate but typically resolve postpartum 2.
• Fluid retention and increased joint laxity in pregnancy are the primary causes of her carpal tunnel syndrome, not permanent nerve damage 2.

Implementation Strategy

Splinting Protocol

• Use a rigid wrist splint that immobilizes the wrist in a neutral position or slightly extended at 0-15 degrees (most often 0-5 degrees) 5.
• Initially wear the splint at night for several weeks; during symptom exacerbation, it can also be used during the day during activities that increase symptoms 5.
• There are no statistically significant differences between individual/traditional orthoses or between rigid/soft orthoses, though rigid splints are generally preferred 5.

Expected Timeline

• Wrist splinting is most effective in cases with minimal or intermediate lesions, which this patient likely has given her 4-week symptom duration 3.
• If relief of symptoms is not obtained after 5 months of splinting treatment, that would be the limit of conservative management 3.
• Re-evaluate at regular intervals throughout pregnancy, but expect improvement or resolution after delivery 2.

Common Pitfalls to Avoid

• Do not proceed directly to injections without attempting conservative splinting first, as injections carry theoretical risks during pregnancy 1.
• Do not rely solely on clinical signs (Tinel's and Phalen's signs have poor sensitivity of 54% and 37% respectively, though high specificity) 4.
• Avoid surgical referral during pregnancy unless there is severe, refractory disease with motor weakness or thenar atrophy, which is not present in this case 1, 2.
• Remember that her tennis playing may need temporary modification during treatment, particularly avoiding repetitive wrist flexion/extension movements that exacerbate symptoms 5.