The Impact of Pregnancy on Functional Neurological Disorder (FND)

Authors: Alexander Lehn, Ingrid Hoeritzauer, Caoimhe McLoughlin, Jon Stone, Syeda Farah Zahir, Jan Coebergh, Yvonne Leavy, Adam Morton, David Palmer

Abstract

Background

Functional neurological disorder (FND) commonly affects women of reproductive age, yet little is known about its interaction with pregnancy and childbirth. We aimed to explore FND symptom changes during pregnancy, delivery and the postpartum period and understand women's experiences of care.

Methods

We conducted a cross‐sectional online survey of women with FND who had experienced pregnancy. The questionnaire was co‐designed with clinicians and individuals with lived experience.

Results

Of 111 respondents, 61 had experienced pregnancy after FND onset. Among 88 who provided onset data, 24% reported symptom onset during pregnancy, delivery, or postpartum, with 1 in 10 reporting onset specifically during the peripartum period. Seven participants described symptom onset or worsening following neuraxial (epidural/spinal) anaesthesia. On a group level, there was no significant change in FND symptoms across pregnancy phases or postpartum. FND symptoms did not worsen with vaginal delivery versus caesarean section. However, women who experienced hyperemesis gravidarum, daily headaches, or instrumented vaginal delivery were more likely to report FND symptom worsening. Although 35% expressed concern about FND during pregnancy and 13% changed pregnancy plans because of FND, the majority reported no difficulties with infant care or breastfeeding. Most participants (85%) received no FND‐specific advice regarding pregnancy, and health professionals were generally perceived to have limited knowledge of FND.

Conclusions

While FND symptoms remain stable for most women during pregnancy, a subgroup experiences significant changes or new onset. There is an urgent need for prospective studies and for developing educational resources to guide care in this understudied area.

Introduction

Functional neurological disorder (FND) is a common cause of neurological disability, affecting women more frequently than men [1]. It manifests with a range of symptoms, including functional/dissociative seizures, movement disorders, sensory symptoms and cognitive difficulties.

The interaction between FND and pregnancy remains poorly understood. This is particularly important given the overlap with psychiatric comorbidities such as depressive disorders and anxiety disorders, including PTSD, which may worsen during the perinatal period [2, 3]. A systematic review of 43 women in 36 case reports gives some insights into possible issues but not to real‐world outcomes [4]. A recent small retrospective study by Catherine et al. in 25 patients with functional seizures showed a high rate of pregnancy complications [5]. This highlights the urgent need for research to guide safe and effective care for pregnant women with FND.

We conducted a cross‐sectional study to investigate the impact of pregnancy, childbirth and the postpartum period on FND symptoms, including associations with perinatal complications, delivery mode and neuraxial anaesthesia. We also explored impacts on infant care, breastfeeding and the perceived adequacy of clinical support.

We tested the following hypotheses, based on our clinical experience and patient FND symptoms often improve during pregnancy, particularly the second trimester.Perinatal complications (e.g., hyperemesis gravidarum, mental health issues) may worsen symptoms.FND symptoms may interfere with infant care and breastfeeding.The intrapartum period may trigger or worsen symptoms, particularly after neuraxial anaesthesia.Clinical guidance and support for pregnant women with FND are limited.

Methods

Study Design

We conducted a cross‐sectional online survey via the SurveyMonkey platform, co‐developed by FND clinicians and individuals with lived experience. The questionnaire then underwent review by independent FND experts to assure content and face validity [6]. Feedback was also gathered from a group of volunteers (females with FND with and without previous pregnancies) to ensure questions were relevant and the language was appropriate. The study received ethical approval from the Metro North Health Human Research Ethics Committee (HREC/2023/MNHA/99899).

Study Procedures

Participants were recruited globally via social media of FND patient groups and investigators, using standardised invitation text. The anonymous, adaptive online survey included an introductory consent page and allowed participants to skip questions to minimise distress. Inclusion was open to people with FND who identified as female and were aged 18 or above. Recruitment ran from October 2023 to January 2024. A free‐text section was included to capture additional insights beyond structured responses.

Analysis

Descriptive statistics were reported for the study population. Means and standard deviations were used for normally distributed variables, while medians and interquartile ranges (IQR) were presented for non‐normally distributed variables. Normality was checked using the Shapiro–Wilk test. Associations were explored using Fisher's Exact test. To explore the changes in severity of FND symptoms across various phases of different pregnancies, Stuart Maxwell Tests were conducted. All analyses were conducted using R Studio (4.2.3) (https://www.r‐project.org/) (R Core Team, 2023). The free text responses were analysed thematically.

Results

Demographics and Symptoms of FND

A total of 157 individuals accessed the survey, with 111 women providing responses after reviewing the study information. Participants had a mean age of 37.1 years (range 18–76). Most (61%) had received an FND diagnosis within the last 5 years (mean duration since diagnosis 4.5 years), though 39% reported symptom onset over a decade ago. Most participants reported a combination of functional neurological symptoms and associated symptoms, including motor symptoms (80%), functional seizures (61%), sensory symptoms (72%), memory symptoms (74%), bowel and/or bladder issues (55%) and swallowing and/or speech difficulties (63%). Additionally, many reported commonly associated symptoms, such as pain (27%) and migraine (39.6%) (see Figure 1).

Onset of FND Symptoms

Of 111 participants, 61 had been pregnant since developing FND, and 54 had given birth. They reported a total of 136 pregnancies, with 20 participants having had two pregnancies since having FND, and 10 having had three or more. Among 88 respondents providing data on symptom onset, 24% reported symptom onset during pregnancy, labour, or 12% (n = 10) during pregnancy, 2% (n = 2) during labour/early postpartum and 9% (n = 8) in the first 12 weeks after birth (see Figure 2).

FND Symptom Changes During Pregnancy

Participants reported symptom changes across 78 pregnancies (Figure 3). On a group level, no significant change in FND symptoms was observed across trimesters, labour, or postpartum, using the Stuart‐Maxwell test.

Six participants who had reported improvement of symptoms in the first trimester moved to having worse symptoms intrapartum (in labour) and one moved from reporting worsening symptoms to better symptoms during these periods. Of the 11 participants who had stable symptoms in the first trimester, three improved and three deteriorated during the second trimester and postpartum periods.

Pregnancy‐Related Complications

Among the 111 participants, 32% (n = 36) reported symphysis pubis dysfunction and 26% (n = 29) reported severe nausea and vomiting during pregnancy (hyperemesis gravidarum). Other complications included chronic daily headaches (29%, n = 32), while 14% noted an improvement in pre‐existing headaches. Additionally, 31% (n = 34) reported other pregnancy‐related complications, including preeclampsia (10%, n = 11), gestational hypertension (2%, n = 2), gestational diabetes mellitus (5%, n = 5) and preterm premature rupture of membranes (2%, n = 2).

A significant association was identified between hyperemesis gravidarum and worsening FND Women who reported hyperemesis gravidarum during the first pregnancy (28%, n = 15) were much more likely to report worsening FND than those without hyperemesis gravidarum (n = 39, 72%): They were more likely to report FND symptoms worsening during labour (83% vs. 32%, p = 0.01) and in the postpartum period (62% vs. 21%, p = 0.04).

Additionally, a trend towards significance was observed between daily headaches and worsening FND symptoms in the third trimester of the first pregnancy (11 out of 17 women with daily headaches worsened (65%, p = 0.05)). A significant association was also noted between daily headaches and worsening symptoms in the first trimester of the second pregnancy (5 out of 7 women with daily headaches reported worsening (71%, p = 0.01)). No significant associations were found for third pregnancies.

Mental Health During Pregnancy

Thirty‐eight women (34%) reported being seen by a mental health professional during pregnancy or within 3 months postpartum. Of these, over half (55%, n = 21) sought care for a pre‐existing mental health condition and 17 (45%) were treated for newly developed symptoms. The most common diagnoses were anxiety disorder (19%, n = 21), depression (16%, n = 18) and PTSD (9%, n = 10).

FND and Giving Birth

Since developing FND, 54 women had given 41% (n = 22) had noninstrumented vaginal deliveries, 12 (22%) instrumented, nine (17%) planned caesareans and 11 (20%) emergency caesareans.

Epidural anaesthesia was used in 32 women (29%) during labour, with five participants (16%) reporting symptom onset and two (6%) reporting worsening FND symptoms afterward. Free‐text responses described both negative and positive effects of epidurals (see supporting material).

Participants were asked if their FND diagnosis caused any difficulty in obtaining their preferred type of birth. 12 women (11%) reported four (4%) faced general difficulties with their birth choices due to FND (not further specified), 2 women (2%) experienced some difficulty but ultimately achieved their desired birth and 6 women (5%) encountered difficulties that meant they were unable to have the birth they wanted.

To explore this issue further, participants were invited to provide additional details through free‐text responses. Participants described various challenges in accessing their preferred birth options due to FND. These included being denied home or water births, difficulty finding an obstetrician willing to take their case, unexpected restrictions on pain relief during labour and concerns about healthcare providers' lack of knowledge about FND (see supporting material for examples).

No differences in FND symptom changes were observed at any postpartum timepoint between women who delivered vaginally and those who underwent caesarean section.

Use of Instrumentation and Changes in FND Symptoms in Vaginal Deliveries

Of the 54 women who had given birth, 28 (52%) responded to questions about symptom changes after vaginal delivery. The 12 women who had vaginal delivery with instrumentation experienced higher rates of symptom worsening compared to those without instrumentation (n = 22) (Figure 4). These differences were statistically significant for days one and two postpartum (p < 0.01), during the first 6 weeks postpartum (p < 0.01) and from 6 weeks to 6 months postpartum (p < 0.01).

Changes in FND Symptoms and Type of Caesarean Section

Among 20 participants with caesarean deliveries (9 planned, 11 emergency), no differences in FND symptom changes were observed at any postpartum timepoint based on caesarean type (Figure 5).

FND and Caring for Babies

Thirty‐five women (32%) reported experiencing concern that their FND symptoms would make it challenging to care for their baby. Additionally, 35% (n = 39) reported significant worry about their FND symptoms during pregnancy. Some participants (n = 14, 13%) stated that they had changed their plans to become pregnant due to their FND. Despite this, 77% (n = 86) reported no difficulty caring for their baby or breastfeeding due to their FND. Only one participant avoided breastfeeding because of FND, and two others due to concerns about experiencing functional seizures.

Advice, Knowledge and Support From Healthcare Professionals

Most women (85%, n = 75) reported not having received advice from a health professional about pregnancy in the context of FND. Of the nine women (10%) who did, three were advised against becoming pregnant, while six were told it was safe to do so. Only 22 women (18%) were offered a specialist appointment relating to their FND during their pregnancy, while 28 women (25%) sought information from other sources, primarily social media or the internet.

Participants were asked to rate the level of knowledge their healthcare professionals demonstrated about FND during their pregnancies and births (Figure 6). Among midwives, obstetricians and GPs, the knowledge base was rated by patients as poor, with over 95% reporting these professions either having never heard of FND or possessing only limited knowledge about it. Participants rated the knowledge of neurologists and psychiatrists involved in their care during pregnancy much higher, with the majority being described as having at least some understanding of FND (95% (n = 74) for neurologists and 77% (n = 53) for psychiatrists).

Most participants felt well‐supported by healthcare professionals during pregnancy and 78% (n = 39) felt somewhat or very supported by their midwives and 79% (n = 41) by their obstetricians. General practitioners also received positive feedback, with 72% (n = 38) of participants feeling somewhat or very supported, as did psychiatrists (71%, n = 27). In contrast, 47% (n = 18) of women felt unsupported by their neurologist (Figure 6).

We found statistically significant associations between knowledge and support provided in all groups of health professionals. Within their individual groups, those health professionals who were rated to have better knowledge about FND were also found to provide better support compared to the ones who were rated to have less knowledge.

Free Text Responses

Participants were given the opportunity to share any advice they wished to leave for other women and/or health professionals. Many women emphasised that pregnancy and childbirth are possible with FND but encouraged others to stay attuned to their bodies and symptoms while receiving appropriate care. Advice for other women included management of energy levels and advocacy for their needs. Several women also commented on the importance of a good support system and proactive planning. Some women highlighted concerns that symptoms might worsen in the perinatal period and how this might be managed. Several commented on the lack of guidance they received during their pregnancies. The importance of a clear diagnosis and good communication was frequently highlighted. Many participants raised the issue of the lack of clear, accessible information about managing FND during pregnancy and labour. Please see the supporting material for examples of the free text responses.

Discussion

There are significant gaps in knowledge and clinical guidance around the management of pregnancy and childbirth in patients with FND [4]. This study underscores these issues and provides important information about the relationship between FND, pregnancy and pregnancy‐related experiences.

At a group level, we found no changes in FND symptom severity during or after pregnancy. Except for hyperemesis gravidarum, the frequency of pregnancy‐related complications in our cohort was similar to the general population and lower than those in a recent case series of 45 pregnancies in 29 patients with functional seizures (18 with functional seizures only, and 11 with comorbid functional seizures and epilepsy): In that group preeclampsia/eclampsia was seen in 22% of pregnancies, gestational hypertension (12.2%), gestational diabetes mellitus (4.9%), small for gestational age (14.6%), caesarean delivery (68%), neonatal intensive care unit admissions (9.8%) and one case each of placental abruption and stillbirth [7]. There should be caution in interpreting this, as it was patient‐reported, but it is a larger population than has been previously reported so we felt it important to note.

Symphysis pubis pain and headaches are experienced in over 30% of pregnancies in the general population. We found a similar frequency in women with FND in this study, which is surprising given that over half of people with FND have chronic pain [8]. Nausea and vomiting affect 35%–91% of pregnant women; hyperemesis gravidarum affects 3%–10% of pregnancies [9, 10, 11]. Notably, a report of hyperemesis gravidarum (in 28% of our FND cohort), was associated with FND symptom worsening during labour and postpartum. This is interesting in light of recent evidence showing that rates of anxiety, depression and PTSD are associated with hyperemesis gravidarum [12]. Many participants in our study reported changes to their headaches during pregnancy, which is also commonly seen in the general population, where around 60% of women notice an improvement in migraines during pregnancy, 20% are unchanged and worsening occurs in 5%–10% [13]. Tension headaches generally improve in 35% of women, are stable in 60% and worsen in 5% of women during that period [14, 15]. The frequency of reported hypertension and pre‐eclampsia appears to be higher than what is reported in the broader population. Hypertension occurs in 5%–10% of pregnancies within the general population, and pre‐eclampsia is observed in approximately 3% [16].

While the frequency of anxiety and related disorders was comparable to that in the general population, new‐onset mental health issues during pregnancy appeared more frequent in women with FND [17]. This may reflect the unique biopsychosocial challenges of the perinatal period. As highlighted in a recent systematic review, pregnancy involves significant physiological and psychological changes, including hormonal shifts and physical strain [4].

Based on clinical experience, we suspected neuraxial anaesthesia might trigger FND. Of the 32 women who had received neuraxial anaesthesia, five reported FND onset and two a flare‐up after administration. This suggests a small, but meaningful risk of the development of FND after neuraxial anaesthesia in susceptible women [18] Instrumental vaginal delivery was more common in our cohort than in the general population and appeared to be associated with more FND symptom worsening than vaginal delivery without instrumentation [19]. We saw no difference in FND‐related outcomes when comparing types of caesarean sections (planned versus emergency). The more general literature on FND highlights the important role of precipitating events that involve the experience of pain, dissociation and unexpected medical events [20, 21, 22]. These are all integral experiences of pregnancy and labour for most women. This makes it plausible that such events may also trigger or worsen FND in pregnancy and the postpartum period and may warrant special discussion and counselling during pregnancy. However, while around one third of participants were concerned that FND might affect baby care, nearly three quarters reported no impact on their ability to care for their child or to breastfeed.

The need for support during the perinatal period was highlighted in the free text responses and the effect of FND and the possibility of support should be discussed and planned for during antenatal care.

Although FND is not commonly encountered in perinatal care, knowledge and support for FND‐related issues are important to providing good care. While most participants reported feeling well‐supported by their healthcare professionals during pregnancy and childbirth, they rated the knowledge base of their midwives, obstetricians and GPs as poor. Free text responses echoed the sentiment that there is a major unmet need in education, both for health professionals as well as for patients and their families. This could be met by the provision of specific FND pregnancy resources, which currently do not exist.

Limitations

This retrospective, self‐report study recruited participants online and is subject to recall bias and selection bias. Additionally, individuals who chose to participate in this self‐report study may systematically differ from those who did not, potentially introducing bias. Symptom and diagnosis data were self‐reported, with no clinical confirmation or opportunity for clarification, limiting reliability. Responses may also reflect varied interpretations of questions. For example, 18 participants listed no core or associated FND symptoms despite identifying as diagnosed, possibly reflecting misunderstanding, omission, or other unknown factors. All other participants reported at least one core symptom of FND. Another example is when participants were asked to indicate both symptoms they had experienced within the past month and symptoms they had ever experienced. In some cases, the proportion reporting symptoms in the past month exceeded those reporting them at any time, which is not logically consistent. We interpret this discrepancy as reflecting a misunderstanding of the survey question by some participants rather than true differences in symptom frequency.

Another issue with using survey methods is the potential for misclassification of symptoms, as participants may misunderstand definitions or rely on personal interpretation. For example, when participants were asked about pregnancy‐related complications, 26% reported having suffered from hyperemesis gravidarum. Hyperemesis gravidarum is a severe condition characterised by persistent vomiting, significant weight loss and dehydration, often requiring medical intervention. It was, however, not specifically defined in the questionnaire, and it is possible that some participants who experienced significant nausea and vomiting (which is common in pregnancy) may have mistakenly selected hyperemesis gravidarum as their response, even if they did not meet the strict clinical criteria for the diagnosis. Also, when we surveyed participants about their FND symptoms, we did not provide them with guidance on disentangling symptoms that may arise from pregnancy itself (e.g., pain, fatigue, sleep disturbance) from those attributable to FND. It is therefore possible that some reports of symptom exacerbation reflect overlapping pregnancy‐related changes rather than FND‐specific effects. This highlights the challenge of using survey methods for medical diagnoses, as responses may reflect personal interpretation rather than clinical assessment. While our data provide insight into pregnancy experiences in women with FND, they should be interpreted with caution, recognising that self‐reported conditions may not always align with clinical diagnoses.

Some patients did not answer all questions, with missing responses mainly occurring later in the survey—likely due to survey length. This pattern suggests missing completely at random (MCAR), where dropouts are unrelated to prior responses, reducing the risk of systematic bias [23, 24]. Survey dropout is classified as MCAR when incompleteness in responses occurs independently of any responses provided before participants discontinue the survey. While this dropout likely did not skew results, it limits confidence in some estimates.

We did not collect data on medication and weight, although obesity and medication use like gabapentinoids—both more common in FND—can affect birth outcomes [25]. This can be a target for reduction prepregnancy when considering preconception counselling, as in other neurological conditions like multiple sclerosis or epilepsy. We did not collect information on birth‐related injury (e.g., tears, etc.), which may have affected the interpretation of worsening symptoms after instrumentation.

We did not systematically collect data on participants' geographical or cultural backgrounds, limiting generalisability. It is possible that cultural and healthcare system differences—such as variations in rates of caesarean sections, availability of neuraxial anaesthesia or attitudes towards mental health and FND—could significantly influence pregnancy experiences and outcomes in women with FND. Therefore, the results should be interpreted primarily within the context of the populations likely reached by our recruitment methods, which were predominantly English‐speaking and based in high‐income countries.

Conclusion and Future Directions

Overall, our findings suggest that pregnancy is generally safe for women with FND. Good, standard obstetric care remains the foundation, but particular attention should be given to recognition of FND, clear communication and coordination across disciplines. Women would benefit from being cared for by a team that is knowledgeable about FND, ensuring that symptoms are not misinterpreted and that specific concerns (e.g., around anaesthesia, labour, or infant care) are addressed proactively. Developing educational resources for both patients and healthcare professionals could help bridge current knowledge gaps and support best practices. This is particularly important for midwives, who often have limited exposure to neurological and psychiatric conditions during their training, yet play a central role in antenatal and perinatal care. These resources should address critical questions such as the potential impact of pregnancy on FND symptoms (for which this study is overall reassuring), pain management strategies, birthing options and postpartum care.

Participants highlighted the value of self‐awareness and advocacy, including tracking symptoms and having documentation from neurologists to support communication with obstetric teams and reduce stress during critical moments.

Future research should focus on prospective longitudinal studies in representative populations to evaluate the impact of pregnancy and childbirth on FND symptoms. Establishing registries for pregnant women with FND could help collect data on outcomes and inform evidence‐based guidelines [26].

Improving care of pregnant women with FND should include preconception counselling and perinatal planning delivered by a multidisciplinary team, including neurology, obstetrics, anaesthetics, mental health and allied health. Counselling should cover medication safety in pregnancy and breastfeeding, common physiological changes during pregnancy (e.g., nausea, dizziness, palpitations) and their potential impact on FND. Optimising mental health is important and referral to perinatal psychiatry or a mental health midwife may be beneficial for some patients.

Discussions should cover delivery options, anaesthesia (including the low risk associated with neuraxial anaesthesia), and practical considerations such as the induction of labour to enable coordinated care. The low risk of intrapartum complications found in this survey may help reassure clinicians and patients.

Continuity of care is another key ideally, a single midwife or small team would support the woman throughout pregnancy, labour and postpartum. Antenatal planning should include third‐trimester anaesthetist review and, where possible, a delivery suite visit. Women who wish to breastfeed may benefit from early contact with a lactation consultant. In addition, the importance of sleep, rest and emotional support during and after pregnancy should not be underestimated. Helping women organise support systems in advance can play a major role in reducing symptom burden and improving maternal wellbeing.

Author Contributions

Alexander Lehn, Ingrid Hoeritzauer, Jon Stone, David Palmer: conceptualisation, writing, review and editing. Syeda Farah Zahir: formal analysis, review and editing. Jan Coebergh and Adam Morton: writing, review and editing. Yvonne Leavy: conceptualisation, review and editing.

Conflicts of Interest

Alexander Lehn: A.L. has received educational grants from Abbott, Medtronic and Ipsen. He has received honoraria for educational presentations from AbbVie and SEER Medical. Ingrid Hoeritzauer: I.H. has a National Research Strategy Career Fellowship from the Chief Scientist Office, Scotland and carries out expert witness work. Caoimhe McLoughlin: C.M. receives funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska‐Curie grant agreement No. 956673. Jon Stone: J.S. has a National Research Strategy Career Fellowship from the Chief Scientist Office, Scotland. He receives honoraria from UpToDate. He carries out expert witness work. He is President‐Elect of the FND Society and is on the board of FND Action. Syeda Farah Zahir: None. Jan Coebergh: None. Yvonne Leavy: None. Adam Morton: None. David Palmer: None.

Supporting information