This month’s Ask the Experts topic is the changes your body undergoes during pregnancy. This week, Julie A. Melchior, MD, diplomate of the American Board of Orthopaedic Surgeons, holder of a Certificate of Added Qualifications in Surgery of the Hand (CAQSH) and member of the American Society for Surgery of the Hand joins us to talk about the hand and wrist problems many women experience while expecting.
Our body changes during pregnancy in many ways. Hands and wrists are a key part of what we do every day and are specific areas that affect many pregnant women as well as new mothers. This can alter what we can and cannot do with our hands, both at work and at home, and as these problems can get worse as pregnancy progresses, I believe this is a topic that will resonate with a lot of women.
Carpal tunnel syndrome
The most common symptoms of carpal tunnel syndrome are numbness and/or tingling in the thumb, index and middle finger and sometimes half of the ring finger, along with pain in the wrist and/or fingers which can go up the forearm and even up towards the shoulder.
The pain can be burning, aching, shooting, stinging, “electric-shock-like”, or any combination of these. Classically, symptoms are worse at night- many women come to see me because they are waking up several times a night with their hand “asleep”, causing them to have to get up and walk around, shake their hand out to wake it up, or hang it over the side of the bed. We all know it is hard enough to sleep when you are pregnant, who needs this in addition? Some daytime activities that often cause symptoms are driving, doing one’s makeup, holding a book or the newspaper, and using a hair dryer. Other symptoms can include dropping things, weakness, and loss of dexterity, which can present as trouble doing one’s buttons, or difficulty picking up small objects such as coins.
The reason carpal tunnel syndrome is so common in pregnancy is primarily because of the increased fluid that is retained in one’s body. This increase in fluid collects everywhere, resulting in swollen hands, difficulty wearing rings and watches, and internally, in increased fluid around the tendons that move our fingers, which live in the carpal tunnel with the median nerve. This is a large nerve that brings feeling to and from the thumb, index and middle fingers and usually half of the ring finger as well, and also feeds the muscles at the base of the thumb which allow us to pinch and bring the thumb across the palm to the small finger. The carpal tunnel is a normal structure, everyone has one in each wrist. It is bone on three sides, with a thick strong ligament (a fibrous structure that connects bone to bone) forming the fourth side on the palm aspect. There is little spare room in the carpal tunnel, so if there is an increase in the volume of the tendons within the tunnel, then there is less room available for the nerve, and the nerve being the softest and most sensitive structure in the tunnel, takes the brunt of it. This results in numbness, tingling, pain, weakness, dropping of things, and loss of dexterity.
What can you do about it?
The first step is to start wearing a wrist splint at night. This will keep your wrist in a neutral, or relatively straight, position which is the best position for your nerve. During the night, many people sleep with their wrists bent one way or the other (flexed or extended, with your arm or hand tucked under your head or your pillow) and this decreases the amount of room available in the carpal tunnel for the nerve. This results in the tiny blood vessels that go to the nerve being cut off, and then we get numbness, tingling and so forth.
Eventually the hand “falls asleep” and this is frequently what wakes people up. The wrist splint (or brace) will prevent these extreme positions and let your nerve rest while you rest. You can also wear the splint during the day if there are certain activities that make your hand go numb, such as driving a car.
Often, this gets worse before it gets better over the course of pregnancy. If the wrist splint isn’t enough, then another option is a corticosteroid (“cortisone”) injection into the carpal tunnel. After the first trimester this can be an option but always discuss the idea of an injection with your obstetrician or family doctor before proceeding. The corticosteroid medication decreases swelling around the tendons within the carpal tunnel, creating more room for the nerve. This can be very helpful in getting you through the pregnancy more comfortably. The last option is surgery, called carpal tunnel release, which opens up the ligament on the palm side of the carpal tunnel to relieve pressure on the nerve. Surgery is very effective but most likely it won’t be necessary. Happily, carpal tunnel syndrome usually gets better once you have had your baby, so surgery may not ever be needed, but it often does not go away right away. I had carpal tunnel syndrome with my first pregnancy and it took a good month before mine went away, so be patient. Occasionally carpal tunnel syndrome persists after delivery and we treat it the same way we do during pregnancy.
Another very common wrist problem in pregnancy and even more so with new mothers is called DeQuervain’s tenosynovitis or tendonitis. This is a problem with two of the tendons that lift your thumb. It can be related to increased fluid retention and hormonal changes during pregnancy, but with new mothers, it is more related to the way one holds your new baby’s head during feedings. If you picture how you hold the baby’s head, your thumb is stretched out away from your hand and back, with your hand angled toward the little finger side of the wrist (called ulnar deviation). This position, when maintained for a period of time, can cause inflammation of the tendons at the wrist, on the thumb side, at the bottom of the thumb. This results in pain along the thumb side of your wrist, and can go up into your forearm. This can cause people to drop things and feel that they’ve lost strength in that hand, and gripping and twisting can be painful and difficult. This area frequently can be swollen, and sometimes people also get catching (triggering) of the thumb with motion. Other less common findings can include a small bump along the inflamed tendons or the nerve that lies over the tendons can get irritated which can cause numbness on the back of your thumb and index finger (unlike carpal tunnel syndrome, which causes numbness on the palm side of the thumb, index and middle fingers).
How do you take care of this? The first step is a wrist and thumb brace. This is different than the brace that one uses for carpal tunnel syndrome- it comes down further on the thumb than the carpal tunnel brace, extending to the end joint on the thumb or stopping just before it. The intent is to prevent the motion of your thumb (that “out and back” position) that is aggravating your tendons. The brace doesn’t help unless you wear it, so you have to really use it. Many new moms say that they don’t like to wear it when they are holding or feeding their baby, but that is the most important time to do so. You can use this brace day and night as much as necessary until the wrist feels better. As the baby gains strength in the neck and develops head control, you have to support their head less and yourtendons calm down. Once you are done with breastfeeding, it usually goes away.
Other options include a corticosteroid injection, which is often very helpful, anti-inflammatory medications such as Ibuprofen or Aleve, if you are able to take such medications (check with your doctor first), and ice on the painful area, 10 minutes twice a day. If these don’t solve the problem, then we can move on to occupational (hand) therapy, occasionally a cast, or lastly surgery to release the tunnel that the tendons live in along the wrist. Again, surgery is not usually needed for this condition but is an option if other treatments don’t resolve the issue.
Julie A. Melchior MD is a diplomate of the American Board of Orthopaedic Surgeons, holds a Certificate of Added Qualifications in Surgery of the Hand (CAQSH) and is a member of the American Society for Surgery of the Hand. She attended Northwestern University for her undergraduate work as well as for medical school, and did her residency training in orthopaedic surgery at UCLA Medical Center. Her hand and upper extremity fellowship was done at the University of Rochester Medical Center in Rochester, New York. As a member of the American Society for Surgery of the Hand’s committee on Public Awareness, she and fellow hand surgeons are working to increase people’s understanding of and knowledge of what hand surgery is and how hand surgeons can help. Dr. Melchior has been in practice for 15 years, initially in California and currently in Colorado, and lectures at various courses on hand surgery. She has two daughters, and has personal as well as professional experience with hand issues during pregnancy. Visit handcare.org for more information about hand and wrist problems.