Cortisone Shots for Hand Pain During Pregnancy and Lactation
What are corticosteroid injections?
Corticosteroids are a type of anti-inflammatory (anti-swelling) medication. There are different types of corticosteroids that can be given by pills or by injections. Injections for musculoskeletal issues are also called “cortisone” or “steroid” injections. In hand surgery, steroid injections can be used to treat many different problems such as carpal tunnel syndrome, joint pain, and tendinitis. The injections are placed directly into the area in the arm where pain or inflammation in located. Medications taken by mouth (pills) will take effect on the whole body as well as the arm. The most common reported side effect of the injections is temporary pain, swelling, or bruising at the location of the shot. In diabetics, increased blood sugars can occur. Since the medication is white, skin white patches or lightening around the injection site can occur. Infections and severe side effects are rare.
What conditions are commonly treated in pregnant or lactating women with corticosteroid injections?
The most common hand, wrist, and arm complaints during pregnancy and during lactation are carpal tunnel syndrome and de Quervain's tenosynovitis.
Carpal Tunnel Syndrome During Pregnancy and Lactation
Carpal tunnel syndrome is compression of a nerve that crosses the wrist called the median nerve. Compression occurs because of swelling, hormone changes, and fluid shifts during pregnancy. Up to 62% of women will have symptoms of carpal tunnel during pregnancy. Symptoms often worsen during the third trimester and are often in both hands. Nighttime worsening symptoms such as pain around the thumb, grip and pinch weakness, and numbness are common. Numbness occurs in the thumb, index and middle, and half of the ring fingers. Often, carpal tunnel syndrome improves after the baby is born but can continue while bottle feeding, nursing or pumping. Hand positioning during feeds, hormonal changes and fluid retention cause worse symptoms.
Braces at night are the first line treatment and help in up to 80% of patients. Cortisone (steroid) injections are used for persistent symptoms at any time if bracing fails. Injections are preferred over pills to avoid any medication reaching the baby through the blood or through the breastmilk. Surgery may even be recommended to treat severe symptoms, weakness, or muscle loss. During pregnancy, the preferred time for surgery is the second trimester. Local anesthesia only is used to avoid the medication reaching the baby in pregnant or lactating women. Within 4 weeks of delivery, up to 85% of patients have complete improvement of their symptoms. If symptoms continue after this time, surgery is considered an option.
DeQuervain’s Tenosynovitis During Pregnancy and Lactation
DeQuervain’s tenosynovitis is pain on the thumb/wrist and is more common after delivery. Pain occurs with bending the wrist for feeds, cradling, or lifting the baby. This condition is often referred to as “mommy wrist.” Other symptoms can occur when positioning during breastfeeding or pumping and hooking/unhooking a bra or lactation gear. Bracing is used both during pregnancy and post-partum. Anti-inflammatories by mouth are used to help pain post-partum but cannot be taken during pregnancy. DeQuervain’s in pregnancy and lactation can improve once the children are at an age at they are beginning to walk or lactation or bottle feeding is done. Bracing can be helpful. However, corticosteroid injections can also be an effective treatment.
Are corticosteroids safe to use in pregnant and lactating women?
Much of the controversy around corticosteroids are based on those taken by mouth (pills) or by veins (IV) as they spread to the whole body including the placenta and milk. That can be important, as corticosteroids are used orally to improve lung tissue development in the fetus during preterm labor and can be lifesaving. Corticosteroid injections that are placed directly into the painful area are considered safest to use during pregnancy and lactation for hand and wrist pain. No studies have shown harm to the mother or baby. Injections are direct into the tendon area or carpal tunnel and do not enter the blood stream. Injections are safer than oral medications and/or surgery for pregnant or lactating women. They are considered the “treatment of choice” when bracing is not effective. Symptoms of carpal tunnel syndrome related to pregnancy or lactation alone improve when pregnancy or lactation is complete. Mothers have reported hand related symptoms up to 3 years surrounding pregnancy and lactation.
Who do I see for a cortisone injection?
Consult a local hand surgeon. It is best to start with bracing and check with your OB before considering any treatment or injections, especially if you have gestational diabetes.
Do I need to "pump and dump"?
There is no need to withhold from feeding or pumping after cortisone injections. If local anesthesia is used during surgery, there is no need to "pump and dump." Obstetricians recommend returning to breastfeeding when you can safely hold your baby.
References:
Ablove RH, Ablove TS. Prevalence of carpal tunnel syndrome in pregnant women. WMJ. 2009 Jul;108(4):194-6. PMID: 19753825.
Filippini C, Saran S, Chari B. Musculoskeletal steroid injections in pregnancy: a review. Skeletal Radiol. 2023 Mar 14. doi: 10.1007/s00256-023-04320-9. Epub ahead of print. PMID: 36917270.
Meems M, Truijens S, Spek V, Visser LH, Pop VJ. Prevalence, course and determinants of carpal tunnel syndrome symptoms during pregnancy: a prospective study. BJOG. 2015;122(8):1112-1118
Osterman M, Ilyas AM, Matzon JL. Carpal tunnel syndrome in pregnancy. Orthop Clin North Am. 2012;43(4):515-520.
Danielle Wilbur is an orthopaedic hand and wrist surgeon in western New York. She trained in orthopaedic surgery at George Washington University and completed a hand fellowship at The Philadelphia Hand Center. She is an associate professor of orthopaedic surgery at the University of Rochester.