IJG-07954; No of Pages 3 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes Kerem D. Seckin a,⁎, Mahmut I. Yeral b, Mehmet F. Karslı c, Ismail B. Gultekin c a b c
Department of Gynecology and Obstetrics, Bingol Solhan Government Hospital, Bingol, Turkey Department of Gynecology and Obstetrics, Giresun Bulancak Government Hospital, Giresun, Turkey Department of Gynecology and Obstetrics, Sami Ulus Women and Children’s Health Training and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 7 November 2013 Received in revised form 4 February 2014 Accepted 7 April 2014 Keywords: Doppler ultrasonography Maternal fasting Neonatal outcomes Ramadan
a b s t r a c t Objective: To investigate the effects of long-lasting maternal fasting on fetal biometry, amniotic fluid volume, fetal Doppler parameters, and neonatal outcomes. Methods: The present study, conducted at Solhan State Hospital, Bingol, Turkey, between July and August 2013 recruited 82 healthy and otherwise normal pregnant women with a gestational age of 29 weeks or more who were fasting for at least 20 days. The control group comprised 87 healthy non-fasting women matched for maternal age, parity, gestational age. Fetal parameters were measured at the beginning and the end of the fasting month. Perinatal outcomes were compared between the groups. Results: There were no significant differences between the groups in fetal biometry, fetal Doppler parameters, or neonatal outcomes. In the fasting group, however, there was a significantly greater decrease in amniotic fluid index during the fasting period (P b 0.001). The number of women who initially had a normal amniotic fluid measurement and subsequently developed oligohydramnios was also significantly higher in the religious fasting group (P b 0.05). Conclusion: Fetal development, Doppler parameters, and neonatal outcomes were not significantly affected in healthy fasting women; however, there was a significant association between fasting and amniotic fluid index. These findings mandate more frequent follow-up visits for this group of women. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Ramadan is a holy month among Muslims and is known as the month of fasting. It is always the ninth month according to the Islamic calendar, and fasting with no eating or drinking lasts for several hours for each day of this month. For centuries, religious Muslim women have maintained Ramadan fasting even when pregnant and, although they believe that it is not harmful to their fetus, they ask for advice during prenatal visits. Religious fasting is particularly observed among populations in the eastern regions of Turkey [1–3]. Fasting may lead to dehydration and metabolic instability [4,5]. Sufficient amniotic fluid and uteroplacental circulation are mandatory for fetal development and wellbeing [6]. Previous studies found that fetal development [7,8] and uterine artery flow patterns [9] were not affected during the fasting period, but another study reported a significant increase in abnormal biophysical scores [10].
⁎ Corresponding author at: Bingol Solhan Government Hospital, Department of Gynecology and Obstetrics, Solhan, Bingol 12700, Turkey. Tel.: +90 506 5152715; fax: +90 426 7112483. E-mail address: [email protected] (K.D. Seckin).
The aim of the present study was to investigate the effects of religious fasting on fetal biometry, fetal Doppler, amniotic fluid index (AFI), and neonatal outcomes among pregnant women in their third trimester.
2. Materials and methods The present study was conducted between July 8 and August 8, 2013, among pregnant women attending a prenatal clinic at Solhan State Hospital, Bingol, Turkey. The local ethics committee gave study approval, and written consent was obtained from all participants. The study group comprised women with singleton pregnancies of 29 weeks or more of gestation who were fasting for at least 20 days. The control group comprised non-fasting pregnant women matched for maternal age, parity, and gestational age. The exclusion criteria were maternal systemic disease, history of previous surgery, and highrisk pregnancies such as fetal anomaly, intrauterine fetal growth retardation, polyhydramnios, preeclampsia, and gestational diabetes mellitus. All sonographic measurements were performed by the same sonographer toward the end of the daily fasting period (between 18:00 and 19:00). An initial examination was carried on the first fasting day, and a second examination was done on the last day of the fasting month.
http://dx.doi.org/10.1016/j.ijgo.2014.02.018 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
2
K.D. Seckin et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
A DC-3 diagnostic ultrasound instrument (Mindray, Schenzen, China) was used for fetal measurements. The parameters were biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), amniotic fluid index (AFI) and accompanying weeks. The Hadlock 1 formula was used to estimate fetal weights [11]. Doppler flow measurements included middle cerebral artery (MCA) and umbilical artery (UA) systole and diastole. The maternal characteristics of the participants were recorded. The participants were followed-up throughout the third trimester, and delivery outcomes were recorded. Statistical analysis was done with SPSS version 17 (IBM, Armonk, NY, USA). Data were compared between the two groups by an independent sample t test. A P value of less than 0.05 was considered to be statistically significant. 3. Results In total, 169 pregnant women were included in the study: 82 in the fasting group, and 87 in the control group. Maternal age, parity, maternal weight at the beginning of pregnancy, gestational age, and maternal weight gain during pregnancy were similar between the 2 groups (Table 1). The mean period of fasting in the study group was 23 ± 2.6 days. The mean fasting time was 18.7 hours (17–20 hours) in the study group and 3.9 hours (0.7–8.0 hours) in the control group (P b 0.01). At the end of the fasting month (Ramadan), the changes in BPD, AC, and FL, and fetal weight gain (FWG) were similar between the groups. There was no significant difference between the 2 groups in Doppler parameters (MCA and UA S/D ratios). However, the AFI measured at the end of the fasting period was significantly lower than that measured at the beginning of the fasting period for women in the fasting group (P b 0.001) (Table 2). There were no differences between the two groups in neonatal parameters such as birth weight, gestational age at time of delivery, admission to the neonatal intensive care unit (NICU), and type of delivery. However, the number of patients who initially had a normal amniotic fluid measurement and subsequently developed oligohydramnios was significantly higher in the religious fasting group than in the nonfasting group (Table 3). 4. Discussion Religious fasting during Ramadan is one of the principal rules of Islamic belief. This Islamic rule is frequently obeyed, especially among populations in the eastern region of Turkey. The fasting hours change each year because the Islamic calendar is lunar [12,13]. Studies have investigated the effects of long-lasting dehydration during fasting [2,14], and most have found no association with Apgar scores, AFI, birth weight or gestational age at the time of delivery [15–17]. The effects of fasting on fetal biometry, AFI, and Doppler parameters (MCA, UA and uterine artery) have also been studied, and fasting was again recorded to have no negative impact on any of these parameters [8,10]. Table 1 Comparison of maternal characteristics between the fasting and non-fasting group. Characteristic
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
Age, y Parity Primary maternal weight, kg Weight gain, kg Fasting, h Gestational age, wk
24 ± 4.2 (19–29) 2.5 ± 0.9 58.6 ± 9.4 5.4 ± 1.86 18.7 (17–20) 34.1 (30–40)
26.1 ± 5.9 (20–32) 2.2 ± 1.1 60.2 ± 11.2 6.2 ± 1.49 3.9 (0.7–8.0) 35.2 (29–39)
0.41 0.56 0.78 0.63 b0.001 0.12
Values are given as mean ± SD or mean (range) unless stated otherwise.
Table 2 Comparison of ultrasonographic indices between the fasting and non-fasting group.a Ultrasonographic index
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
ΔBPD, mm ΔAge-BPD, wk ΔFL, mm ΔAge-FL, wk ΔAC, mm ΔAge-AC, wk ΔAFI FWG, g UA Doppler, S/D MCA Doppler, S/D MCA/UA ratio, S/D
9.17 3.7 8.62 3.6 41.7 3.6 20.1 485.4 2.45 4.71 1.95
9.41 3.7 8.6 3.7 41.3 3.6 11.5 461.8 2.41 4.56 1.92
0.26 0.18 0.81 0.12 0.45 0.25 b0.001 0.16 0.86 0.98 0.72
± ± ± ± ± ± ± ± ± ± ±
1.5 0.31 1.79 0.4 6.7 0.43 11.2 162 0.37 0.72 0.43
± ± ± ± ± ± ± ± ± ± ±
1.3 0.37 1.84 0.3 5.2 0.36 6.4 84 0.35 0.8 0.42
Abbreviations: ΔBPD, increase in biparietal diameter; ΔAge-BPD, increase in gestational age of biparietal diameter; ΔFL, increase in femur length; ΔAge-FL, increase in gestational age of femur length; ΔAC, increase in abdominal circumference; ΔAge-AC, increase in gestational age of abdominal circumference; FWG, fetal weight gain; MCA, middle cerebral artery; UA, umbilical artery; S/D, systolic to diastolic ratio. a Values are given as mean ± SD unless stated otherwise.
Clinical studies of Doppler parameters found that the ratio of MCA to UA was more sensitive than MCA Doppler measurements alone [18–20]. In the present study, however, MCA, UA, and MCA/UA ratio Doppler measurements showed no significant difference between the fasting and non-fasting groups. Similar Doppler findings were reported by Hizli et al. [21]. In the present study, fetal biometric parameters such as BPD, AC, FL and FWG were compared with no significant differences between the two groups, similar to the results of Moradi [22]. Whereas Mirghani et al. [10] found that the frequency of cesarean delivery and NICU admission was higher in a fasting group than in a non-fasting group, there was no significant difference in these outcomes between the two groups in the present study. Fetal birth weights and gestational age at time of delivery were also similar between the two groups. In previous studies on fasting during Ramadan, the average time of fasting was 9–15 hours, as compared with 18.7 hours (range 17–20 hours) in the present study. Fasting was performed between 04:00 and 08:00 in a hot climate (average temperature 35 °C) for at least 20 days. In contrast to the studies of Dikensoy et al. [8] and Kamyabi et al. [23] there was a significant decrease in AFI in the fasting group as compared with the non-fasting group. Because the Doppler parameters were within normal limits, the decrease in AFI might be related to maternal dehydration. Obstetricians should be concerned about fetal well-being because of the decreased AFI and low biophysics scores in the third trimester, which in turn lead to a need for more frequent prenatal visits for these pregnant women. The observed lack of effect of fasting on neonatal outcomes despite the decrease in AFI might be related to the small study population. In summary, there was no association of religious fasting (prolonged cessation of food and fluid intake) with fetal parameters such as biometry, Doppler flow parameters, and neonatal outcomes among pregnant women. However, there was a significant association between fasting
Table 3 Fetal outcomes and type of delivery.a Outcome
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
Birth weight, g Gestational age at delivery, wk NICU admission Cesarean delivery Occurrence of oligohydramnios
3089 ± 300 37.2 (36–40) 4 (4.8) 20 (24.3) 20 (23.8)
3450 ± 352 38.6 (37–39) 3 (3.4) 22 (25.2) 6 (7.3)
0.09 0.11 0.48 0.92 0.03
Abbreviation: NICU, neonatal intensive care unit. a Values are given as mean ± SD, mean (range), or number (percentage) unless stated otherwise.
Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
K.D. Seckin et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
and decreased AFI, and fasting shortened the interval for oligohydramnios development. Therefore, close prenatal surveillance is warranted for these women. Conflict of interest The authors have no conflicts of interest. References [1] Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004;27(10):2306–11. [2] Robinson T, Raisler J. “Each one is a doctor for herself”: Ramadan fasting among pregnant Muslim women in the United States. Ethn Dis 2005;15(1):S1–S99. [3] Joosoph J, Abu J, Yu SL. A survey of fasting during pregnancy. Singapore Med J 2004;45(12):583–6. [4] Dikensoy E, Balat O, Cebesoy B, Ozkur A, Cicek H, Can G. The effect of Ramadan fasting on maternal serum lipids, cortisol levels and fetal development. Arch Gynecol Obstet 2009;279(2):119–23. [5] Malhotra A, Scott PH, Scott J, Gee H, Wharton BA. Metabolic changes in Asian Muslim pregnant mothers observing the Ramadan fast in Britain. Br J Nutr 1989;61(3): 663–72. [6] Osol G, Mandala M. Maternal uterine vascular remodeling during pregnancy. Physiology (Bethesda) 2009;24(1):58–71. [7] Ziaee V, Kihanidoost Z, Younesian M, Akhavirad MB, Bateni F, Kazemianfar Z, et al. The effect of Ramadan fasting on outcome of pregnancy. Iran J Pediatr 2010;20(2): 181–6. [8] Dikensoy E, Balat O, Cebesoy B, Ozkur A, Cicek H, Can G. Effect of fasting during Ramadan on fetal development and maternal health. J Obstet Gynaecol Res 2008;34(4):494–8. [9] Mirghani HM, Salem M, Weerasinghe SD. Effect of maternal fasting on uterine arterial blood flow. J Obstet Gynaecol Res 2007;33(2):151–4.
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[10] Mirghani HM, Weerasinghe DS, Ezimokhai M, Smith JR. The effect of maternal fasting on the fetal biophysical profile. Int J Gynecol Obstet 2003;81(1):17–21. [11] Hadlock FP, Harrist RB, Sharman RS, Deter RL, Park SK. Estimation of fetal weight with the use of head, body, and femur measurements: a prospective study. Am J Obstet Gynecol 1985;151(3):333–7. [12] Aksungar FB, Eren A, Ure S, Teskin O, Ates G. Effects of intermittent fasting on serum lipid levels, coagulation status and plasma homocysteine levels. Ann Nutr Metab 2005;49(2):77–82. [13] Leiper JB, Molla AM, Molla AM. Effects on health of fluid restriction during fasting in Ramadan. Eur J Clin Nutr 2003;57(2):S30–8. [14] Prentice AM, Prentice A, Lamb WH, Lunn PG, Austin S. Metabolic consequences of fasting during Ramadan in pregnant and lactating women. Hum Nutr Clin Nutr 1983;37(4):283–94. [15] Kaplan M, Eidelman AI, Aboulafia Y. Fasting and the precipitation of labor. The Yom Kippur effect. JAMA 1983;250(10):1317–8. [16] Cross JH, Eminson J, Wharton BA. Ramadan and birth weight at full term in Asian Moslem pregnant women in Birmingham. Arch Dis Child 1990;65(10):1053–6. [17] Hefni M, Fikry SAH, Abdalazim M, Abdelkhalik MA. Fasting in Ramadan and preterm labour. Saudi Med J 1993;14(1):130–2. [18] Ozeren M, Dinç H, Ekmen U, Senekayli C, Aydemir V. Umbilical and middle cerebral artery Doppler indices in patients with preeclampsia. Eur J Obstet Gynecol Reprod Biol 1999;82(1):11–6. [19] Makhseed M, Jirous J, Ahmed MA, Viswanathan DL. Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. Int J Gynecol Obstet 2000;71(2):119–25. [20] Ebrashy A, Azmy O, Ibrahim M, Waly M, Edris A. Middle cerebral/umbilical artery resistance index ratio as sensitive parameter for fetal well-being and neonatal outcome in patients with preeclampsia: casecontrol study. Croat Med J 2005;46(5): 821–5. [21] Hızlı D, Yılmaz SS, Onaran Y, Kafalı H, Danışman N, Mollamahmutoğlu L. Impact of maternal fasting during Ramadan on fetal Doppler parameters, maternal lipid levels and neonatal outcomes. J Matern-Fetal Neonatal Med 2012;25(7):975–7. [22] Moradi M. The effect of Ramadan fasting on fetal growth and Doppler indices of pregnancy. J Res Med Sci 2011;16(2):165–9. [23] Kamyabi Z, Naderi T. The effect of Ramadan fasting on amniotic fluid volume. Saudi Med J 2004;25(1):45–6.
Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes Kerem D. Seckin a,⁎, Mahmut I. Yeral b, Mehmet F. Karslı c, Ismail B. Gultekin c a b c
Department of Gynecology and Obstetrics, Bingol Solhan Government Hospital, Bingol, Turkey Department of Gynecology and Obstetrics, Giresun Bulancak Government Hospital, Giresun, Turkey Department of Gynecology and Obstetrics, Sami Ulus Women and Children’s Health Training and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 7 November 2013 Received in revised form 4 February 2014 Accepted 7 April 2014 Keywords: Doppler ultrasonography Maternal fasting Neonatal outcomes Ramadan
a b s t r a c t Objective: To investigate the effects of long-lasting maternal fasting on fetal biometry, amniotic fluid volume, fetal Doppler parameters, and neonatal outcomes. Methods: The present study, conducted at Solhan State Hospital, Bingol, Turkey, between July and August 2013 recruited 82 healthy and otherwise normal pregnant women with a gestational age of 29 weeks or more who were fasting for at least 20 days. The control group comprised 87 healthy non-fasting women matched for maternal age, parity, gestational age. Fetal parameters were measured at the beginning and the end of the fasting month. Perinatal outcomes were compared between the groups. Results: There were no significant differences between the groups in fetal biometry, fetal Doppler parameters, or neonatal outcomes. In the fasting group, however, there was a significantly greater decrease in amniotic fluid index during the fasting period (P b 0.001). The number of women who initially had a normal amniotic fluid measurement and subsequently developed oligohydramnios was also significantly higher in the religious fasting group (P b 0.05). Conclusion: Fetal development, Doppler parameters, and neonatal outcomes were not significantly affected in healthy fasting women; however, there was a significant association between fasting and amniotic fluid index. These findings mandate more frequent follow-up visits for this group of women. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Ramadan is a holy month among Muslims and is known as the month of fasting. It is always the ninth month according to the Islamic calendar, and fasting with no eating or drinking lasts for several hours for each day of this month. For centuries, religious Muslim women have maintained Ramadan fasting even when pregnant and, although they believe that it is not harmful to their fetus, they ask for advice during prenatal visits. Religious fasting is particularly observed among populations in the eastern regions of Turkey [1–3]. Fasting may lead to dehydration and metabolic instability [4,5]. Sufficient amniotic fluid and uteroplacental circulation are mandatory for fetal development and wellbeing [6]. Previous studies found that fetal development [7,8] and uterine artery flow patterns [9] were not affected during the fasting period, but another study reported a significant increase in abnormal biophysical scores [10].
⁎ Corresponding author at: Bingol Solhan Government Hospital, Department of Gynecology and Obstetrics, Solhan, Bingol 12700, Turkey. Tel.: +90 506 5152715; fax: +90 426 7112483. E-mail address: [email protected] (K.D. Seckin).
The aim of the present study was to investigate the effects of religious fasting on fetal biometry, fetal Doppler, amniotic fluid index (AFI), and neonatal outcomes among pregnant women in their third trimester.
2. Materials and methods The present study was conducted between July 8 and August 8, 2013, among pregnant women attending a prenatal clinic at Solhan State Hospital, Bingol, Turkey. The local ethics committee gave study approval, and written consent was obtained from all participants. The study group comprised women with singleton pregnancies of 29 weeks or more of gestation who were fasting for at least 20 days. The control group comprised non-fasting pregnant women matched for maternal age, parity, and gestational age. The exclusion criteria were maternal systemic disease, history of previous surgery, and highrisk pregnancies such as fetal anomaly, intrauterine fetal growth retardation, polyhydramnios, preeclampsia, and gestational diabetes mellitus. All sonographic measurements were performed by the same sonographer toward the end of the daily fasting period (between 18:00 and 19:00). An initial examination was carried on the first fasting day, and a second examination was done on the last day of the fasting month.
http://dx.doi.org/10.1016/j.ijgo.2014.02.018 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
2
K.D. Seckin et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
A DC-3 diagnostic ultrasound instrument (Mindray, Schenzen, China) was used for fetal measurements. The parameters were biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), amniotic fluid index (AFI) and accompanying weeks. The Hadlock 1 formula was used to estimate fetal weights [11]. Doppler flow measurements included middle cerebral artery (MCA) and umbilical artery (UA) systole and diastole. The maternal characteristics of the participants were recorded. The participants were followed-up throughout the third trimester, and delivery outcomes were recorded. Statistical analysis was done with SPSS version 17 (IBM, Armonk, NY, USA). Data were compared between the two groups by an independent sample t test. A P value of less than 0.05 was considered to be statistically significant. 3. Results In total, 169 pregnant women were included in the study: 82 in the fasting group, and 87 in the control group. Maternal age, parity, maternal weight at the beginning of pregnancy, gestational age, and maternal weight gain during pregnancy were similar between the 2 groups (Table 1). The mean period of fasting in the study group was 23 ± 2.6 days. The mean fasting time was 18.7 hours (17–20 hours) in the study group and 3.9 hours (0.7–8.0 hours) in the control group (P b 0.01). At the end of the fasting month (Ramadan), the changes in BPD, AC, and FL, and fetal weight gain (FWG) were similar between the groups. There was no significant difference between the 2 groups in Doppler parameters (MCA and UA S/D ratios). However, the AFI measured at the end of the fasting period was significantly lower than that measured at the beginning of the fasting period for women in the fasting group (P b 0.001) (Table 2). There were no differences between the two groups in neonatal parameters such as birth weight, gestational age at time of delivery, admission to the neonatal intensive care unit (NICU), and type of delivery. However, the number of patients who initially had a normal amniotic fluid measurement and subsequently developed oligohydramnios was significantly higher in the religious fasting group than in the nonfasting group (Table 3). 4. Discussion Religious fasting during Ramadan is one of the principal rules of Islamic belief. This Islamic rule is frequently obeyed, especially among populations in the eastern region of Turkey. The fasting hours change each year because the Islamic calendar is lunar [12,13]. Studies have investigated the effects of long-lasting dehydration during fasting [2,14], and most have found no association with Apgar scores, AFI, birth weight or gestational age at the time of delivery [15–17]. The effects of fasting on fetal biometry, AFI, and Doppler parameters (MCA, UA and uterine artery) have also been studied, and fasting was again recorded to have no negative impact on any of these parameters [8,10]. Table 1 Comparison of maternal characteristics between the fasting and non-fasting group. Characteristic
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
Age, y Parity Primary maternal weight, kg Weight gain, kg Fasting, h Gestational age, wk
24 ± 4.2 (19–29) 2.5 ± 0.9 58.6 ± 9.4 5.4 ± 1.86 18.7 (17–20) 34.1 (30–40)
26.1 ± 5.9 (20–32) 2.2 ± 1.1 60.2 ± 11.2 6.2 ± 1.49 3.9 (0.7–8.0) 35.2 (29–39)
0.41 0.56 0.78 0.63 b0.001 0.12
Values are given as mean ± SD or mean (range) unless stated otherwise.
Table 2 Comparison of ultrasonographic indices between the fasting and non-fasting group.a Ultrasonographic index
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
ΔBPD, mm ΔAge-BPD, wk ΔFL, mm ΔAge-FL, wk ΔAC, mm ΔAge-AC, wk ΔAFI FWG, g UA Doppler, S/D MCA Doppler, S/D MCA/UA ratio, S/D
9.17 3.7 8.62 3.6 41.7 3.6 20.1 485.4 2.45 4.71 1.95
9.41 3.7 8.6 3.7 41.3 3.6 11.5 461.8 2.41 4.56 1.92
0.26 0.18 0.81 0.12 0.45 0.25 b0.001 0.16 0.86 0.98 0.72
± ± ± ± ± ± ± ± ± ± ±
1.5 0.31 1.79 0.4 6.7 0.43 11.2 162 0.37 0.72 0.43
± ± ± ± ± ± ± ± ± ± ±
1.3 0.37 1.84 0.3 5.2 0.36 6.4 84 0.35 0.8 0.42
Abbreviations: ΔBPD, increase in biparietal diameter; ΔAge-BPD, increase in gestational age of biparietal diameter; ΔFL, increase in femur length; ΔAge-FL, increase in gestational age of femur length; ΔAC, increase in abdominal circumference; ΔAge-AC, increase in gestational age of abdominal circumference; FWG, fetal weight gain; MCA, middle cerebral artery; UA, umbilical artery; S/D, systolic to diastolic ratio. a Values are given as mean ± SD unless stated otherwise.
Clinical studies of Doppler parameters found that the ratio of MCA to UA was more sensitive than MCA Doppler measurements alone [18–20]. In the present study, however, MCA, UA, and MCA/UA ratio Doppler measurements showed no significant difference between the fasting and non-fasting groups. Similar Doppler findings were reported by Hizli et al. [21]. In the present study, fetal biometric parameters such as BPD, AC, FL and FWG were compared with no significant differences between the two groups, similar to the results of Moradi [22]. Whereas Mirghani et al. [10] found that the frequency of cesarean delivery and NICU admission was higher in a fasting group than in a non-fasting group, there was no significant difference in these outcomes between the two groups in the present study. Fetal birth weights and gestational age at time of delivery were also similar between the two groups. In previous studies on fasting during Ramadan, the average time of fasting was 9–15 hours, as compared with 18.7 hours (range 17–20 hours) in the present study. Fasting was performed between 04:00 and 08:00 in a hot climate (average temperature 35 °C) for at least 20 days. In contrast to the studies of Dikensoy et al. [8] and Kamyabi et al. [23] there was a significant decrease in AFI in the fasting group as compared with the non-fasting group. Because the Doppler parameters were within normal limits, the decrease in AFI might be related to maternal dehydration. Obstetricians should be concerned about fetal well-being because of the decreased AFI and low biophysics scores in the third trimester, which in turn lead to a need for more frequent prenatal visits for these pregnant women. The observed lack of effect of fasting on neonatal outcomes despite the decrease in AFI might be related to the small study population. In summary, there was no association of religious fasting (prolonged cessation of food and fluid intake) with fetal parameters such as biometry, Doppler flow parameters, and neonatal outcomes among pregnant women. However, there was a significant association between fasting
Table 3 Fetal outcomes and type of delivery.a Outcome
Fasting group (n = 82)
Non-fasting group (n = 87)
P value
Birth weight, g Gestational age at delivery, wk NICU admission Cesarean delivery Occurrence of oligohydramnios
3089 ± 300 37.2 (36–40) 4 (4.8) 20 (24.3) 20 (23.8)
3450 ± 352 38.6 (37–39) 3 (3.4) 22 (25.2) 6 (7.3)
0.09 0.11 0.48 0.92 0.03
Abbreviation: NICU, neonatal intensive care unit. a Values are given as mean ± SD, mean (range), or number (percentage) unless stated otherwise.
Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
K.D. Seckin et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
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Please cite this article as: Seckin KD, et al, Effect of maternal fasting for religious beliefs on fetal sonographic findings and neonatal outcomes, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.018
