International Journal of Gynecology and Obstetrics (2004) 87, 233 --- 236

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ARTICLE

Median and ulnar nerve conduction in pregnancy

M. Eogana, C. OBrienb, D. Carolanb, M. Fynesa, C. OHerlihya,*
a

Department of Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland b National Maternity Hospital, Holles Street, Dublin 2, Ireland
Received 25 June 2004; received in revised form 3 September 2004; accepted 8 September 2004

KEYWORDS
Carpal tunnel syndrome; Pregnancy; Neurophysiology

Abstract Objective: A prospective, observational study assessed median and ulnar nerve conduction during pregnancy, to identify the optimum test for differentiating physiological effects of pregnancy from pathological carpal tunnel syndrome (CTS). Methods: Pregnant women (n =18) and age- and parity-matched non-pregnant controls (n =13) were recruited. Symptomatic and neurophysiological evaluations were performed. Median and ulnar nerve latencies and intrapalmar latency (difference between median and ulnar nerve latencies) were computed. Results: Median nerve distal latency is more prolonged in pregnant women compared with non-pregnant controls. Median nerve latency is more prolonged in pregnant women with symptoms of CTS than in asymptomatic women. The difference between median and ulnar nerve conduction (normal b0.2 ms) discriminates well between symptomatic and asymptomatic pregnant women. Conclusions: Intrapalmar latency is proposed as a useful diagnostic test for classification of carpal tunnel syndrome during pregnancy. D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Poster presentation at the 24th Annual Meeting of the Society of Maternal Fetal Medicine, New Orleans. February 27 2004. [Eogan M, OBrien C, Carolan D, Fynes M, OHerlihy C. Evaluation of pathological carpal tunnel syndrome in pregnancy. Am J Obstet Gynecol 2003;189(6):S146]. * Corresponding author. Tel.: +353 1 6373216; fax: +353 1 6627586. E-mail address: colm.oherlihy@ucd.ie (C. OHerlihy).
B

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment disorder, resulting from compression of the median nerve at the wrist. Pregnancy is one of the most frequent physiological conditions associated with CTS, with quoted incidences in pregnancy ranging from 2.3% to 62% [1 3]. Affected pregnant women commonly report waking at night with parasthesiae, which can be

0020-7292/$ - see front matter D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.09.005

234 relieved by shaking the symptomatic hand. In addition to pain and parasthesiae, clumsiness and weakness in the affected hand may also be described; these symptoms are worrying for pregnant women who will soon be caring for a young baby. Although the majority experience symptomatic improvement postnatally, a proportion of sufferers (up to 5% at 12 months [4] postpartum) describe continuing symptoms and consequent disability if the syndrome remains untreated. In advanced cases, the thenar muscle atrophies, and power is lost. Median nerve compression results from either increased volume of the contents of the carpal tunnel, or reduction in the actual size of the tunnel (Fig. 1). The median nerve is 94% sensory and only 6% motor [5], so that gradual onset of sensory loss, pain and parasthesiae over its anatomic distribution (the radial three and a half digits) are the commonest initial symptoms (Fig. 2). Likely causes of CTS in pregnancy include fluid retention and musculoskeletal changes in the transverse carpal ligamentwhich reduce the diameter of the carpal tunnel [4]. The resulting diagnostic conundrum requires differentiating as to when this neuropathy is physiological, as an epiphenomenon of pregnancy and when it becomes pathological and worthy of continuing postnatal assessment. Although a presumptive diagnosis may be made based on symptoms, research has indicated that diagnostic tests for CTS (Tinnels Test, Phalens Test and the Median Nerve Compression Test) are unreliable [6], with only neurophysiological evaluation providing objective evidence of median nerve function [7]. This study aimed to determine phys-

M. Eogan et al.

Figure 2

Sensory distribution of the median nerve.

iological and pathological values for median nerve conduction during pregnancy, so as to provide diagnostic criteria for predicting postnatal neurological recovery. As the ulnar nerve runs outside the flexor retinaculum, it is not subject to the same

Figure 1

The carpal tunnel.

Median and ulnar nerve conduction in pregnancy compressive forces as the median nerve; thus, ulnar nerve conduction rates can be used as a comparative standard to the median nerve. To aid differentiation between physiological and pathological changes, it was also considered important to evaluate individual latencies for both nerves separately and in comparison. By differentiating dphysiologyT from dpathologyT, the evidence base available for patients might be improved. Rather than advising pregnant women to adopt an expectant policy, electrodiagnostic evaluation could be instituted, permitting tailoring of prognostic advice according to the results obtained. Furthermore, accurate diagnosis might permit identification of a cohort of women who would benefit from early postnatal intervention to prevent thenar atrophy.

235

3. Results
Thirty-one subjects were recruited, comprising pregnant women, with gestations ranging from 27 to 41 weeks (n =18) and non-pregnant controls of mixed parity (n =13); 13 pregnant women (72%) described symptoms of carpal tunnel syndrome. Median and ulnar nerve latencies were both affected by pregnancy; the results are summarised in Table 1. Median nerve latency was statistically significantly more prolonged in pregnant than in non-pregnant women. While latencies for median and ulnar nerves were within normal limits (normal b2.1F0.2 ms) [10], values for the pregnant population fell at the upper limit of accepted normal ranges. In the pregnant cohort, median and ulnar nerve conduction was more prolonged in symptomatic, compared with asymptomatic women (Table 1). The pregnant group as a whole showed a median nerve latency of 2.1 ms, while symptomatic pregnant women showed a median latency of 2.3 ms. In contrast, asymptomatic pregnant women had latencies of 1.7 ms, similar to the non-pregnant population (1.8 ms) ( P =0.91). Intrapalmar comparative differences between median and ulnar nerve latencies were most significant and correlated with the presence or absence of symptoms (normal b0.2 ms) [9]. In the non-pregnant cohort, a difference of just 0.06 ms between median and ulnar nerve latencies was seen. In the pregnant population as a whole,

2. Materials and methods

Pregnant women and age- and parity-matched nonpregnant controls were recruited at The National Maternity Hospital, Dublin. Following explanation of the aims and methods of the study, written informed consent was obtained. Symptoms of CTS were sought on history. Electrodiagnostic evaluation was performed on all subjects. Segmental median and ulnar nerve distal latencies over an 8-cm transpalmar distance were evaluated by stimulating with a transcutaneous pulse of electricity, which induced an action potential in the nerve under assessment. The recording surface electrode then detected the wave of depolarisation, and the latency of this response was recorded [8]. Values for both median and ulnar nerve latencies were obtained and the results compared by subtracting the ulnar latency from that of the median nerve. In the absence of pathology, the median and ulnar nerves should conduct an impulse at similar rates, so that latencies of both nerves should be analogous (difference b0.2 ms) [9]. This measurement permits differentiation of systemic effects of pregnancy on nerve latency from local compressive effects, which would affect median nerve velocity alone. Data were computerised and analysed using SPSS. Group comparisons were assessed using the MannWhitney U test. Throughout statistical analysis, the significance level was set at 0.05. Symptomatic patients were referred to their attending obstetrician for review and appropriate treatment.

Table 1 Mean distal latencies and intrapalmar latencies for pregnant and non-pregnant populations and for symptomatic and asymptomatic pregnant cohort
Nerve Pregnant Nonpregnant 1.8 1.8 minus ulnar) 0.06 Pregnant without symptoms P value 0.03 0.004 Distal latency (ms) Median 2.1 Ulnar 1.6 Intrapalmar latency (median 0.5 Pregnant with symptoms Distal latency (ms) Median 2.3 Ulnar 1.7

0.003

1.7 1.6

.02 NS

Intrapalmar latency (median minus ulnar) 0.6 0.15

0.04

NS=nonsignificant. Normal values for median and ulnar nerve latency should be b2.1F0.2 ms [10] and the intrapalmar difference should be b0.2 [9].

236 however, the difference between median and ulnar nerve conduction velocities was statistically significantly greater at 0.5 ms. Furthermore, intrapalmar conduction discriminated well between symptomatic and asymptomatic pregnant women, with an intrapalmar difference of 0.15 ms in the asymptomatic pregnant group, increasing to 0.6 ms in symptomatic pregnant women.

M. Eogan et al. physiological in pregnancy emphasises the importance of performing the optimum diagnostic test. Pregnant women with hand parasthesiae should undergo median and ulnar transpalmar distal latency evaluation and intrapalmar comparative testing. This study suggests that a difference between median and ulnar conduction velocities of N0.3 ms indicates a significant neuropathy rather than an effect of pregnancy alone. As this abnormality may affect long-term muscle bulk and function, symptomatic treatment during pregnancy and postpartum review are desirable. These findings suggest that all pregnant patients with symptoms of CTS should be assessed and managed in a specialist clinic. Within this context, provision of postpartum electrodiagnostic studies would allow correlation with antenatal studies, thus providing further guidance as to where the physiological effects of pregnancy end and pathological carpal tunnel syndrome begins.

4. Discussion
This study shows that conduction velocities of both median and ulnar nerves are affected by pregnancy and that prolongation of median nerve latencies correlates with symptoms of CTS. It is apparent, in addition, that the intrapalmar comparative study is a good discriminant between subtle pregnancyrelated effects and symptomatic CTS. Median nerve conduction is statistically significantly slower in pregnancy than in non-pregnant women. Ulnar nerve conduction was unexpectedly faster in the pregnant population that in the non-pregnant cohort in this sample. Although this difference in latencies is statistically significant, it is noteworthy that both values are within normal limits (b2.1 ms), so the difference is not clinically relevant. When the pregnant population is considered in isolation, both median and ulnar nerve conduction are more prolonged with symptomatic CTS. Not unexpectedly, a statistically significant difference was only found in median nerve latency, since it is compression of this nerve that leads to the characteristic symptoms of the syndrome. These results indicate that median transpalmar studies provide a good indicator of subtle changes in nerve conduction in pregnancy, but that comparison with ulnar nerve conduction provides greater diagnostic discrimination. Although 72% of pregnant women studied described symptoms of CTS, because antenatal subjects were recruited by invitation, this incidence does not represent a true reflection of antenatal prevalence. It is logical that women with CTS symptoms might be more likely to consent to participation in the study. Absence of symptoms in the non-pregnant population is consistent with the much lower incidence of CTS outside of pregnancy. The finding that neurophysiological changes, which would be diagnostic of carpal tunnel syndrome in the non-pregnant population, could be

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