The Effect of 3rd Trimester Ramdan Fasting on Obestetric Outcome
Conditions: Fasting, Fetal Growth Retardation, Antenatal (Disorder)
Sponsor: Ain Shams Maternity Hospital

trimester Ramadan fasting on Obstetric outcome 
 
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The Effect of 3
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trimester Ramdan 
 
rd
The Effect of 3
 
fasting on Obestetric outcome
 
 
Thesis protocol
 
Submitted for partial fulfillment of master degree in
 
Obstetrics & Gynecology
 
BY
 
Ahmed Khalil Abd Elshafi
 
M.B, B.Ch, Benha University 2011
 
Resident of Obstetrics & Gynecology Ghamra Military Hospital
 
 
Under supervision
 
Prof .Mohammed Abd Allah ElMaraghi
 
Professor of Obstetric & Gynecology
 
Faculty of medicine – Ain shams university
 
 
Dr. Ayman Abd Elkader Mohammed
 
Lecturer of Obstetrics & Gynecology
 
Faculty of medicine - Ain shams university
 
2015)
) 

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Introduction 
Ramadan is the holiest month in the Islamic calendar 
and Muslims fast during this month. Ramadan fasting is one 
of the five pillars of Islam, and is observed by millions of 
Muslims all over the world. Believers are commanded to 
abstain from food, drink and conjugal relationships from 
sunrise to sunset as a sign of restraint and introspection. Food 
and fluid intake are mainly nocturnal and usually, food 
frequency and quantity, sleep duration at night and daily 
physical activity are reduced. The food habits are not similar 
outside and during Ramadan in that the proportion of fat, 
protein and carbohydrate intake can differ during Ramadan. 
There is a tendency to consume foods and drinks that are richer 
in carbohydrates than those consumed during other months of 
the year. The quality of ingested nutrients can also differ 
during Ramadan compared with the rest of the year. The 
period in which the person fasts may vary depending on the 
geographical location of the country and the season of the 
year, and can be as long as 18 hours/day in the summer of 
temperate regions (Ziaee, 2006). 
During the month of Ramadan, adult Muslims abstain 
from eating, drinking, smoking, and sexual activity from 

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sunrise to sunset. Fasting during Ramadan forms one of the 
five pillars of Islam, along with announcement of faith, 
praying five times a day, Zakat (giving to the poor), and Hajj 
(pilgrimage to Mecca). In 2010, there were approximately 1.6 
billion Muslims worldwide and this number is growing 
(Kridli, 2015). 
Concurrence of fasting with pregnancy as a 
physiological condition introduces some controversies 
regarding the condition of the mother and the fetus. Pregnant 
women are exempt from fasting if it poses a risk to the fetus; 
however, many still fast while others are more cautious about 
its practice. Many pregnant show great interest in fasting and 
are able to perform this religious practice; however, they are 
concerned about their fetus and inquire about the possible 
associated complications during pregnancy According to the 
statics, in West Africa, 90% of pregnant women fasted during 
the month of Ramadan. The prolonged hunger presents itself 
as hypoglycemia or hyperketonuria, which may affect the 
neonatal weight, neonatal mortality and disability. During 
fasting, pregnant and breastfeeding women experience 
changes in metabolism, sleep patterns and daily physical 
activity (Cunigham et al., 2010). 

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Most 
Muslims 
observe 
Ramadan 
every 
year. 
Exemption from fasting is permitted for women who are 
pregnant or breastfeeding, but the missed fasts must be 
completed before the next Ramadan (Rashed, 2010).  
Muslim women choose to fast during pregnancy 
because of a sense of religious duty, familial support, positive 
views on fasting, and difficulty in completing the missed fasts 
at another time. A previous study found that Muslim women 
believed the only reason not to fast would be perceived harm 
to mother or fetus, but that fasting during pregnancy is safe for 
healthy women. Women feel strong spiritual, emotional, 
physical, and social benefits from fasting; it is seen as a way 
of maintaining cultural identity and unity among their 
communities (Robinson et al., 2005). 
Many women asking their obstetrician if fasting is safe 
for their baby or not? There have been many studies on 
metabolic changes and different aspects of human health 
during and after Ramadan, but there have been few studies on 
the effect of fasting on pregnancy outcome and there are also 
some controversies in the findings of different studies (Ziaee 
et al., 2006). 

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Ramadan fasting during pregnancy is a controversial 
issue. A group of pregnant women do not fast due to the 
probable harmful effect on fetal health. Although Ramadan 
fasting may be postponed to the postnatal period, some 
pregnant women obey it as a religious activity (Joosoph, 
2004). 
  
There are several reports regarding the effects of 
Ramadan fasting on the human metabolism. Fasting leads to a 
decrease in serum glucose, insulin, lactate, and carnitine, as 
well as an increase in free fatty acids, hydroxy butirate, 
cholesterol, and triglyceride levels. As we know, maternal 
glucose infusion causes stimulation of short-term fetal activity 
and uteroplacental blood flow is essential for fetal 
development and wellbeing (Osol, 2009). 
During the month of Ramadan, healthy adults abstain 
from food and drink from dawn to sunset. Pregnant are 
allowed, if they choose, to postpone the fast until after 
delivery. However, most of the women would like to fast with 
their families rather than doing this alone later. Therefore, 
most Muslim pregnant women fast during the holy month of 
Ramadan. Consequently, diet restriction and fasting could 
adversely affect pregnancy outcome, especially if Ramadan 

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falls during the hot summer months with long days of fasting 
(Mirghani, 2006).

(Study Protocol)
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Aim of the Work 
This study aimed to find out the association between fasting during 
Ramadan and obstetric outcome in third trimester regarding to hypoglycemic 
symptoms, fetal growth, AFI, mode of delivery, birth weight and neonatal 
outcome.  
Study question: 
In pregnant women in the third trimester, does fasting during the holy 
month of Ramadan has a poor obstetric outcome regarding to hypoglycemic 
symptoms, fetal growth, AFI, mode of delivery, birth weight and neonatal 
outcome?  
Patient and Methods 
Type of the study : 
Prospective Comparative Cohort Study. 
Study setting : 
EL- Demerdash outpatient clinic. 
Duration of the setting : 
The Holy month of Ramadan (from 18th June To 16th July 2015.Averge 
hours of fasting 16 hours. 
Population (study will include): 
The patients will be recruited from outpatient clinic during Ramadan then 
followed during the holy month then grouped into three groups A ,B, C 
regarding fasting state  and each group contain 53 patient after exclusion drop 
out patient 
A- Non fasting group  

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B- Partially fasting group (average days of fasting 10-20 day). 
C- Totally fasting group 
Inclusion criteria: 
• Within the range of 20 – 35 years. 
• 3rd trimester pregnancy (starting from 28 weeks) which is going to be 
calculated according to the date of the last menstrual period & confirmed 
by ultrasonography. 
•  Normal healthy women with average body mass index (BMI). Normal 
range (18.5 to 25). 
• Women included have no medical disorder. 
Exclusion criteria : 
• History of systemic disorder. 
• Smoking narcotics or alcohol use. 
• Have previous history of fetal loss. 
• Multiple pregnancies. 
Methodology  
Women who fulfilled the eligibility criteria are going to be subjected to: 
1) Complete history taking: 
a. Personal history. 
b. Medical history. 
c. Obstetric history. 
d. History of present pregnancy: with special emphasis on signs & 
symptoms of hypoglycemia in the form of fatigue, dizziness, fainting, 
blurred vision, vomiting. 
e. Fetal kicks. 
2)  General examination: assessment of vital data. 
3)  Ultrasound fetal biometry every 2 weeks till delivery looking for 

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o Fetal biometry. 
o AFI (ammonic fluid index) 
o Doppler. 
4) Fetal weight after delivery. 
Sample Size Justification: 
The required sample size has been calculated using the G*Power Software 
(Universität Düsseldorf, Germany).  
The primary outcome measure is the difference between the three study 
groups as regards the fetal birth weight. The secondary outcome measures are 
the incidence of unwanted fetal outcomes (e.g., IUGR, PTL, or NICU admission). 
Since there is currently no adequate information regarding the outcome 
measures in patients who are fasted for the whole or part of the month, the current 
exploratory study would target an effect size that could be clinically relevant.  
So, it is estimated that a sample of 53 patients in each study group (total 
159 patients) would achieve a power of 80% (type II error, 0.2) to detect a 
statistically significant difference among the three groups as regards the fetal 
birth weight for a medium effect size (eta squared, η2) of 0.25. The effect size (eta 
squared, η2) is calculated as follows: η2 = between-group sum of squares/total 
sum of squares. This calculation used a two-sided F test with a numerator degree 
of freedom (k-1) of 2, a denominator degree of freedom (n-k) of 156, and a 
confidence level of 95% (type I error, 0.05), where k is the number of groups and 
n is the total sample size.This sample size of 159 patients would achieve a power 
of 93% (type II error, 0.07) to detect a statistically significant difference among 
the three groups as regards the secondary outcome measures (IUGR, PTL, and 
NICU admission) for a medium effect size (w) of 0.3. The effect size (w) is 
calculated as follows: w =√(χ^2/N), where χ2 is the chi-squared statistic and N 

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is the total sample size. This calculation used a two-sided chi-squared test with a 
confidence level of 95% (type I error, 0.05).  
  
A medium effect size of η2 = 0.25 or w = 0.3 for the primary or secondary 
outcome measures, respectively, has been chosen as it could be regarded as a 
clinically relevant difference to seek in this exploratory study.  
Assuming an expected drop-out rate of approximately 10%, a total sample 
size of 180 patients (60 patients per group) will be recruited.  
 
 

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Statistical Methods: 
Data will be collected, tabulated, then analyzed using IBM© SPSS© 
Statistics version 22 (IBM© Corp., Armonk, NY). 
Normally distributed numerical data will be presented as mean and SD, 
and skewed data as median and interquartile range. Qualitative data will be 
presented as number and percentage. Comparison of normally distributed 
numerical data will be done using one-way analysis of variance (ANOVA). 
Skewed data will be compared using the Kruskal Wallis test. Categorical data 
will be compared using the chi-squared test, or Fisher’s exact test when 
appropriate. A two-sided p-value <0.05 will be considered statistically 
significant.