International Journal of Gynecology and Obstetrics 81 (2003) 1721

Article

The effect of maternal fasting on the fetal biophysical profile

H.M. Mirghani*, D.S.L. Weerasinghe, M. Ezimokhai, J.R. Smith
Department Obstetrics & Gynaecology, Faculty of Medicine & Health Sciences, United Arab Emirates University, Al-Ain,
United Arab Emirates
Received 5 September 2002; received in revised form 25 October 2002; accepted 6 November 2002

Abstract
Objectives: To determine fetal biophysical profile changes in women observing Ramadan with uncomplicated
singleton pregnancy. Methods: In this cross-sectional observational study healthy women who were observing
Ramadan at 30 weeks or more of gestation were recruited as well as a non-fasting control group matched for age,
parity, and gestational age. Ultrasound examination included assessment of amniotic fluid volume, fetal bladder
volume, fetal biophysical profile, and umbilical artery Doppler flow. Results: A total of 162 pregnant women were
observed. Mean umbilical artery pulsatility index, vertical amniotic pool depth, and fetal bladder volume were similar
in the study and control groups. However, there was a significant difference in biophysical scores between the two
groups. In the fasting group, 30 of 81 fetuses (37%) had a score of 6y8 compared with 11 of 81 fetuses (13.6%) in
the control group (Ps0.001). All fetuses in both groups with a biophysical score of 6y8 showed no breathing
movements. Conclusions: Fetal breathing movements are reduced during maternal fasting.
2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights
reserved.
Keywords: Maternal fasting; Ramadan; Fetus; Biophysical profile

1. Introduction
Fasting during Ramadan is one of the five main
religious practices of Islam. Healthy adults are
expected to abstain from food and drink during
daylight hours throughout the month of Ramadan.
Pregnant women are allowed, if they choose, not
to observe Ramadan. However, after delivery, they
are expected to fast the number of days they
missed during Ramadan. Most would like to fast
with their families rather fasting alone later.
*Corresponding author. Tel.: q971-3-703-9562; fax: q9713-767-2067.

Pregnant women respond to short-term fasting

with a sequence of metabolic changes. These
include hypoglycemia, raised circulating free fatty
acids and ketones, and reduced concentration of
amino acids, a condition known as accelerated
starvation w1x. Pregnant women fasting during
Ramadan show a significant fall in glucose, insulin, lactate, and carnitine levels and a rise in
triglyceride concentrations w2x. These changes are
not only related to fasting duration but also to the
gestational age w3x.
Fetal response during Ramadan has been less
investigated. Cross et al. w4x found no effect of

0020-7292/03/$30.00 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd.
All rights reserved.
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H.M. Mirghani et al. / International Journal of Gynecology and Obstetrics 81 (2003) 1721

fasting on the mean human fetal birth weight at

any gestational age. Several animal studies
explored the effect of hypoglycemia and dehydration on the fetus. These studies revealed a significant increase in fetal plasma, urine osmolality, and
sodium, arginine, and vasopressin plasma concentrations. This was associated with a significant
decrease in the glomerular filtration rate and fetal
urine flow w5x. Hypoglycemia was found to reduce
the rate of ovine fetal breathing movements w6,7x.
In human fetuses, a short-term increase in fetal
activity was noticed with maternal glucose infusion
w8x. Oosterhof et al. w9x observed increased fetal
urine production by human fetuses in response to
acute maternal rehydration.
Methods to assess fetal well-being during the
antenatal period include fetal kick count, cardiotocography, biophysical profile (BPP), and Doppler
flow studies. The biophysical profile is a standard
and reliable method of assessing fetal well-being:
perinatal mortality ranges from 0, when all variables are normal, to 600 per 1000, when all biophysical profile variables are abnormal w10,11x.
The omission of cardiotocography as a component
of BPP does not alter significantly the sensitivity
or the specificity of BPP w12x.
To our knowledge no study has examined changes in fetal activity, fetal biophysical profile, bladder
volume, amniotic fluid volume and Doppler flow
changes in pregnant women observing Ramadan.
Changes in these activities will have a great impact
on the interpretation of fetal surveillance during
Ramadan.
The objective of this study is to determine the
fetal biophysical profile changes in pregnant women observing Ramadan.
2. Subjects and methods
A cross-sectional observational study was carried out at Al-Ain Hospital in United Arab Emirates, between November 17, 2001 and December
12, 2001, this corresponded to the 2nd and 27th
day of the month of Ramadan 2001.
A consecutive sample of healthy pregnant women observing Ramadan and already booked for
ultrasound examination was recruited. Included
were healthy women observing Ramadan with

uncomplicated singleton pregnancies at 30 weeks

or more of gestation. All women gave informed
consent to participate in the study. For each fasting
pregnant woman, a non-fasting healthy pregnant
woman matching for age, parity, and gestational
age was recruited as a control from the antenatal
clinic.
The womens age, parity, duration of pregnancy,
ethnic group, and duration of fasting (last meal or
drink) were documented. A 3.5 MHz convex
transducer (ATL Apogee 800 plus, Ultrasound
Imaging Corporation, Atlanta, GA) was used for
an ultrasound examination that included amniotic
fluid volume (AFV), fetal bladder volume, biophysical profile, and umbilical artery Doppler flow
studies.
The modified biophysical profile (cardiotocography not included) was scored according to Manning criteria w12x as follows:
d Fetal movements: three or more body or limb
movements within 30 min.
d Fetal tone: one episode of active extension and
flexion of the limbs; opening and closing of
hand within 30 min.
d Fetal breathing movements: one or more episode greater than 30 s within 30 min (Hiccups
are considered breathing activity).
d Amniotic fluid volume: a single 2 cm=2 cm
pocket is considered adequate.
For each variable a score of 2y2 was given if it
fulfilled criteria, a score of 0y2 was recorded if
the criteria were not met after 30 min of ultrasound
observation. If all criteria were met in less than
30 min, no further biophysical assessment was
needed. The total score for the above biophysical
profile was 8. Cardiotocography (CTG) was not
part of the biophysical score. The total biophysical
score and the scores of each of its 4 components
were compared separately between the study and
control groups.
Bladder volume was calculated as described by
Hedriana et al. w13x. All measurements were determined with electronic calipers on the ultrasound
screen. The maximum length was obtained from
the neck of the urinary bladder to the inner edge
of the fundus. The transducer was then rotated at
right angles to the long axis of the bladder, and

H.M. Mirghani et al. / International Journal of Gynecology and Obstetrics 81 (2003) 1721

the largest depth and width were obtained from

the largest transverse plane. The bladder volume
was calculated with the following formula w14x:
Volume ml.s0.46323q1.39394
=Sagittal area mm2.
The Ethical Committee of the Faculty of Medicine and Health Sciences, United Arab Emirates,
approved this study.

19

Table 1
Biophysical profile components detected in fasting and nonfasting groups
BPP components

Fasting
(ns81)

Breathing movements
Gross body movements
Fetal tone
Normal amniotic fluid volume

51
81
81
81

(63%)
(100%)
(100%)
(100%)

Non-fasting
(ns81)
70
81
81
79

(87%)*
(100%)
(100%)
(98%)

The asterisks represent significant differences.

*
Ps0.001

2.1. Statistical analysis

Collected data were subjected to statistical analysis using SPSS software. Statistical comparison
was made using the Pearson chi-square test for
analysis of changes between the two groups. A Pvalue less than 0.05 was considered significant.
3. Results
A total of 162 pregnant women were studied,
81 of whom were fasting and an equal number
was not (the non-fasting control group). The mean
("S.D.) number of consecutive fasting days was
17"8.7 days. The mean time in hours since the
last oral intake was 8.0"2 h in the study group
and 2.6"1.2 h in the control group.
The mean"S.D. estimated fetal weight for the
study group was 2488"599 g and 2362"643 g
for the control group. In the study group three
(3.7%) of the estimated fetal weights were below
the 10th percentile and five (6.2%) above the 90th
percentile, compared with five (6.2%) and four
(4.9%), respectively, in the control group. These
differences were not statistically significant. The
mean"S.D. umbilical artery pulsatility index (PI)
was 1.0"0.15 in the study group and 1.0"0.19
in the control group. The mean measurement of
vertical amniotic pool depth in the study group
was 4.9"1.1 cm and 4.8"1.2 cm in the control
group. The mean"S.D. fetal bladder volume in
the study group was 19.6"9.9 ml and 17"7.7 ml
in the control group. The differences in the amniotic fluid and bladder volume were not statistically
significant. A significant difference between the
two groups was noted in the biophysical score
(BPS); in the fasting group 30 (37%) of fetuses

had a score of 6y8 compared with 11 (13.6%) in

the control group (Ps0.001). In all fetuses (control and study) with a BPS of 6y8, breathing
movements were the component that was significantly affected. All other biophysical profile components were normal in the two groups (Table 1).
An absence of breathing movements was not
related to the number of consecutive fasting days.
The BPS score was 8y8 in all women who had
their last meal within 4 h prior to ultrasound
examination.
4. Discussion
Our results show no effect of Ramadan on the
estimated fetal weight during pregnancy, and support the report by Cross et al. w14x that the
Ramadan fast has no effect on the birthweights of
newborns at full term. It seems that the fetus can
withstand intermittent and short durations of hypoglycemia without losing much of its glycogen
storage. This study shows no evidence of amniotic
fluid or fetal bladder volume alteration with maternal fasting. We opted for fetal bladder volume
measurement rather than fetal urine flow to assess
renal urine production because the fetal urine flow
estimation requires additional multiple bladder
measurements, which are clinically cumbersome
and inconvenient to patients. It should be noted
that a single measurement of the fetal bladder
volume is a poor predictor of fetal urinary output
because of the inherent behavior of the fetal
bladder, which is a pliable connective tissue that
changes in configuration. The effect of fasting on
urine production remains controversial. Dodd et
al. w17x reported no effect of 48 h of dehydration

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H.M. Mirghani et al. / International Journal of Gynecology and Obstetrics 81 (2003) 1721

on ovine fetuses urine output whereas Schreyer et

al. w15x was able to demonstrate a significant
reduction in amniotic fluid volume in pregnant
ewes dehydrated for 54 h. This might be due to
the difference between the duration of dehydration
in the two studies. In our study the mean duration
of fasting was 8 h. In our study the unchanged
amniotic fluid volume might indirectly suggest
that no major long-term changes in renal function
are affected during Ramadan fasting.
The effect of glucose level on umbilical artery
flow velocity remains unclear. Most of the information in humans is from studies on pregnant
diabetic patients, and most suggest that changes in
Doppler velocity waveforms are not influenced by
blood glucose regulation w16x. Ursem et al. w17x
observed an increase in umbilical artery peak
systolic velocity in pregnancies complicated by
insulin-dependent diabetes mellitus, and a slight
decrease in the pulsatility index was associated
with hypoglycemia. In our study no significant
umbilical artery pulsatility index differences were
detected between the two groups.
The maternal glucose level affects many fetal
activities and movements. Maternal intravenous
glucose administration tends to increase fetal body
movements, with no changes in laryngeal or esophageal activity. Fetal body movement responses to
glucose administration seems to be biphasic, with
an initial decrease observed during the first hour
of glucose infusion w18x followed by a significant
increase in activity w19x. Fetal movements in pregnancies complicated by diabetes mellitus respond
differently to maternal glycemic levels. They might
show no change or even decrease w20x.
The significant difference in fetal breathing
movements and biophysical score remains an
important finding in this study, with possible clinical implications for women observing Ramadan.
It might also suggest the need for BPP interpretation, to inquire about the time of last oral intake
in populations that do not observe Ramadan. Fetal
breathing movements are significantly affected by
maternal blood glucose level w8x. The reduced fetal
breathing movements in fasting pregnant women
may be explained by the fact that these movements
increase significantly following maternal ingestion
of glucose, with the maximum rate coinciding with

peak maternal plasma glucose concentration w21x.

This effect occurs as early as 24 weeks of gestation
w22x. The fact that other fetal movements remain
unaffected raises the following question: are the
regulatory mechanism for other fetal movements
different, do they operate at different glucose
levels? The question is difficult to answer from
this study because it did not measure maternal or
fetal blood glucose levels.
5. Conclusion
The biophysical profile of the fetus is significantly reduced by maternal food and water deprivation during Ramadan. The component of the
profile that is mostly affected is fetal breathing
movements. The mechanism of this observation is
unknown, but has clinical implications when interpreting fetal biophysical scores in pregnant women
observing Ramadan. Further detailed studies are
needed to identify the glucose levels at which fetal
breathing movements become affected.
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