الفهرس 
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Abstract
The current review is to clarify the evidence base available on maternal and perinatal effects of Muslim Ramadan fasting during pregnancy through systematic review of published literature in medical journals and databases and meta-analysis of the results of the studies to be included in the review.
Searches were carried out in EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar,. Reference lists of eligible studies were checked by two reviewers for other potentially eligible studies for inclusion. The search was limited by dates from 1998 to 2018 and also was limited to English-only publications.
Meta-analysis was performed using comprehensive metaanalysis version 3.0 software. In case of quantitative outcomes Mean±SD and total sample count were collected then the mean differences were pooled to calculate the weighted mean, while in case of qualitative outcomes events and total sample count were collected then the relative rates were pooled to calculate the weighted relative rate. Heterogenity (I2) index was calculated to test variation of pooled estimated for each outcome. Forest plot were used to present the individual and weighted estimates. The level of significance was taken at P value < 0.050 is significant, otherwise is non-significant.
Primary outcome investigated was Fetal growth parameters and secondary outcomes investigated were Maternal weight gain, Mode of delivery, Average, minimum and maximum no. of fasting hours per day, Average, minimum and maximum no. of fasting days per month, Sense of unbearable weakness and fatigability, Ketonuria/ketonemia, Serum insulin level, Blood glucose level, Blood urea and creatinine levels, Umbilical and middle cerebral arteries Doppler indices, Amniotic fluid volume, Fetal heart rate tracing, Maternal perception of fetal movements, Gestational age at delivery, Anthropometric measurements, Need for NICU admission, Congenital malformations.
Maternal weight gain (kg) in the first trimester was reported in one study and the results showed statistically significant lower in fasting group as the p value 0.003* but clinically non- significant as the difference in Mean±SE -0.3±0.1kg. Maternal weight gain in the second trimester was reported in five studies, and the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -0.6±0.3kg. Maternal weight gain in the third trimester was reported in eight studies, and the results showed statistically significant lower in fasting group as the p value <0.001* and clinically significant as the difference in Mean±SE -8.7±2.6kg.
Normal Vaginal Delivery in the first, second, third trimester, the results showed that Normal Vaginal Delivery was non-significantly different.
Unbearable weakness and fatigability in the third trimester was reported in one study. And the results showed significantly higher in fasting group as the Relative rate value 8.5%.
Ketonuria/ketonemia in the second, third trimester, and the results showed non-significantly different.
Serum insulin level in the second trimester, and the results showed that Maternal serum insulin level in the second trimester was significantly lower in fasting group.
Blood glucose level in the second, third trimester, and the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -10.4±7.3.
Fetal BPD (mm) in the first and the results showed statistically significant lower in fasting group as the p value 0.011*, but clinically non- significant as the difference in Mean±SE -0.2±0.1,(mm). fetal BPD (mm) in the second, third trimester, and the results showed statistically non- significant lower in fasting group as the p value 0.197, 0.796.
Fetal FL (mm) in the, second, third trimester, and the results showed statistically non-significant lower in fasting group as the p value 0.087, 0.176796.
Fetal AC (mm) in the, second, third trimester, and the results showed statistically non- significant lower in fasting group as the p value 0.273, 0.689.
Umbilical and middle cerebral arteries Doppler indices in third trimester, showed non-significant results.
Amniotic fluid volume in the second trimester, showed significant results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -1.6±1.2 (cm). Amniotic fluid volume in the third trimester, the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE --1.3±0.5(cm).
Gestational age at delivery in the second trimester, the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -0.8±0.2(week). Gestational age at delivery in the third trimester, the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -0.7±0.3 (week).
Birth weight in the first trimester, the results showed statistically non-significant lower in fasting group as the p value 0.361. Birth weight in the second trimester, the results showed statistically significant lower in fasting group as the p value <0.003* but clinically non- significant as the difference in Mean±SE -65±22 (gm). Birth weight in the third trimester, the results showed statistically significant lower in fasting group as the p value <0.001* but clinically non- significant as the difference in Mean±SE -68±22 (gm).
Birth height in the first, second trimester, showed non-significant results. Birth height in the third trimester, the results showed statistically significant lower in fasting group as the p value <0.033* but clinically non- significant as the difference in Mean±SE -0.4±0.2 (cm). Birth height in the third trimester was reported in eight studies, and the results showed statistically significant lower in fasting group as the p value <0.001* and clinically significant as the difference in Mean±SE -0.4±0.2 (cm).
Neonatal head circumference in the first, second, trimester, showed non-significant results. Neonatal head circumference in the third trimester, the results significant lower in fasting group as the p value 0.001* but clinically non- significant as the difference in Mean±SE -0.2±0.1 (cm).
Need for NICU admission in the first, third, trimester, showed non-significant results.
This meta-analysis did not find any significant associations between Ramadan fasting and pregnancy outcome. Although studies were drawn from a large literature base, only a relatively small number met the inclusion criteria for analysis, limiting the breadth of robust conclusions. Until more definitive data are available, clinicians and other pregnancy healthcare providers cannot make firm recommendations that Ramadan fasting has no adverse consequences for mother or infant. Further observational studies of the effects of Ramadan fasting are required. Even if individual studies are not sufficiently large to determine differences in rare outcomes such as stillbirth or neonatal death, these should still be reported to facilitate subsequent meta-analysis. Additional studies are also needed to explore the origin of the considerable heterogeneity in observations; these should determine the effects of fasting in the periconceptional period, in different trimesters of pregnancy and whether geographical location, time of year and consequent duration of fasting alters the effect. Thus, well-designed studies investigating Ramadan fasting during pregnancy are needed to investigate the full impacts on maternal and fetal health, as well as to give potential fasting mothers an informed choice whilst addressing an issue that could have enduring public health consequences.