pregnancy with cardiac disease and ramadan fasting

1. PROFESSOR SHABNAM NAZ SHAIKH
MBBS (GOLD MEDALIST) ,MCPS,FCPS.
DEPTT: OF OBSTETRICS AND GYNECOLOGY
CMC,SMBB MEDICAL UNIVERISITY LARKANA
PREGNANT WOMEN WITH CARDIAC DISEASES AND
FASTING

2. INTRODUCTION
• The holy month of Ramadan is one
of the five pillars of Islam. This is
9th month of the Islamic calendar,
During this holy month, adult
Muslims are required to refrain
from all oral intake of food, water,
beverages, drugs, and from sexual
act between dawn and sunset to
learn patience, self-restraint,
sacrifice, and, above all, God-
consciousness.

3. • During the Ramadan fast, Muslims
eat two meals a day, one before
dawn (sehri meal) and the other
shortly after sunset (Iftar meal).
( intermittent fasting )
• The change of dietary patterns and
meal schedule is accompanied by
changes in sleeping patterns..
This change in life-style, in
terms of obtaining the daily
calorie intake via two meals
with alteration of medication
schedule or reduction in
sleep duration, might affect
patients with cardiovascular
diseases (CVD).

4. It is clearly stated in the Quran
(chapter 2, verse 184) that an
illness or medical condition of
any kind that makes fasting
injurious to a person’s health
makes them exempt from
fasting.

5. • Islamic law gives
permission for pregnant
and breastfeeding women
to opt out of fasting if she
fears that it will harm her
health or the health of her
baby.
Missed days of fasting can
be made up at a later date,
or if this isn’t possible, a
‘Fidia’ can be paid by
providing food for someone
in poverty for every missed
day of fasting.

6. some pregnant Muslim women decide to
fast during Ramadan. This is a very
personal decision and will depend on her
own circumstances such as
• the stage of pregnancy,
• how you are feeling and
• Your physical and mental health status.
• if you have experienced any problems
so far in your pregnancy.
• The time of year Ramadan falls (e.g.
during long hot summer days) and
work commitments may also affect
your decision

7. • Fasting should be discussed with
your doctor so that you can have
a health check,
• identify any potential
complications you may be at risk
of when fasting and get their
advice on whether fasting is
likely to harm mother or fetus

8. What happens to the body during fasting
• During a fast, our bodies will first use glucose
(sugars) for energy.
• After around 8 hours, these will run out and
our bodies will use fat.
• This can result in hypoglycemia (low blood
sugar) especially in mothers who are diabetic.
This can also leave pregnant women feeling
tired and weak
• Additionally, the long summer days means
women are fasting for up to 18 hours and are
therefore at risk of dehydration in pregnancy

9. What are the challenges for pregnant women during fasting
• Low calories
• Imbalanced nutrition.--- More prone to nutritional deficiencies
• Less fluid intake--- prone to dehydration
• Reduced vitamins and mineral supplements
during pregnancy increase caloric requirement
from 25 to 30 calories per kg body wt. that
would not maintained during fasting

10. Factors to be considered before fasting
• Gestation of pregnancy during
Ramadan
• Hot or cold days
• Short or long days
• Nutrition status
• Fetus status
• Physical activities
• Pre-existing medical condition
• Pre-existing medical
condition
Severe anemia or
malnutrition
• Heart condition
• Peptic ulcer
• Diabetes requiring medication
• Chronic kidney problem
• Chronic liver condition
• History of clots formations
Infection

11. Is fasting during pregnancy is safe?
• Muslim women may seek advice from health practitioners regarding the safety of
Ramadan fasting; however the current information available to pregnant women
is contradictory and clear guidance is lacking.
• Research is still ongoing in this area and although the evidence is not clear cut,
many experts believe it is not a good idea to fast during pregnancy.
• There is some evidence to suggest that pregnant women who fast during
Ramadan may have smaller placentas and/or babies with slightly lower birth
weights, compared to women who don’t fast.
• Fasting may also increase the risk of becoming dehydrated, especially if Ramadan
falls during the summer days with 18 hrs.' of fasting , and this may affect the
kidney functions and liquor volume
•
However, other studies have not found any differences between babies
who are born to mothers who have fasted and those who have not
fasted during Ramadan.

12. • BMC Pregnancy and Childbirth volume 18,
Article number: 421 (2018)
• meta analysis of studies concluded that Ramadan fasting does
not adversely affect birth weight although there is insufficient
evidence regarding potential effects on other perinatal
outcomes. Further studies are needed to accurately determine
whether Ramadan fasting is associated with adverse maternal or
neonatal outcome.
• In this study 18,920 pregnancies were exposed to Ramadan
fasting.
• Birth weight was reported in 21 studies and was not affected by
maternal fasting .
• Placental weight was significantly lower in fasting mothers
although this observation was dominated by a single large study.
• No data were presented for perinatal mortality. Ramadan fasting
had no effect on preterm delivery

13. • The impact of fasting during pregnancy may depend on
• the overall health of the mother,
• the stage of pregnancy and
• the time of year Ramadan occurs.
• available evidence regarding associations between Ramadan fasting
and pregnancy outcomes needs to be evaluated. More research is
needed to fully understand what impact fasting may have on the
health and development of the baby and what that may mean for the
child’s health in later life.

14. If I decide to fast, is there anything I can do to make it more
manageable for me and my baby?
• Pregnancy is quite a demanding time for body in terms of nutrients and fluids
it needs.
• If women are considering taking part in Ramadan during pregnancy, she
should ist take an advice with obstetrician and cardiologist so that they can
offer some advice and perform any necessary examination and
investigations
• If She decide to consider fasting than she should advice to consider fasting
on some but not all days of the month e.g. fasting on alternate days or on
Fridays to try ,and make it a bit more manageable

15. • she should be warn for symptoms of
(WARNING SIGNS )
• dizziness, headache, tiredness, Weakness,
fatigue dry mouth , Irritability, and
reduced UOP (less than three or four
times a day).
• excessive hunger or thirst
• Nausea/vomiting
• Dysuria, fever, flanks pain ,
• Preterm contraction
• Decrease fetal movement.

16. If I feel unwell and experience symptoms during Ramadan, what should I do?
• If you start to experience symptoms such as dizzy,
faint, weak, confused or tired during fasting, even
after resting
• , you should break your fast immediately with a
sweet drink, to replace lost sugar and fluids, and a
salty snack, to replace lost salt, or an oral
rehydration solution
• If chest pain, breathlessness, during fasting, break
fast immediately If the symptoms do not settle or
you are concerned, immediately contact your
cardiologist for advice.
• try to reduce the risk of dehydration; stay cool in
the shade, don’t over-exert yourself, and try to
drink plenty of fluids once you have broken your
fast
Fidia for break of fasting is to feed 60 poor persons

17. What should I eat during Ramadan?
• At Suhoor (sehri) try to eat foods which release
energy slowly (low glycemic index foods) such as
whole meal pasta, bread, oat and bran based
cereals, beans and unsalted nuts,
• Eat these with fruit and vegetables,
• remember to drink plenty of water.
At Iftar time,
eat a well-balanced meal with complex
carbohydrates and fruits/ vegetables.
Avoid deep-fried and fast burning foods such as
cakes, mithai, samosas, pakoras etc.
Ensure you drink plenty of water.
Make sure you are still taking your
supplements (folic acid and vitamin D) and
eating a healthy balanced diet during
Ramadan so that you are getting all the
nutrients
• avoid strenuous physical activity;
• get adequate sleep –
• Stay cool during day
• Vitamin supplements

19. How do I know if I can fast with my heart condition?
Conditions in which fasting is not advised;
• Fontan circulation
• Mustard/Senning repair
• Cyanotic congenital heart disease (low oxygen levels)
• Pulmonary hypertension (raised blood pressure in
the lungs)
• Severe narrowing of valve
• Pregnancy and complex congenital heart disease .
• patients with acute cardiac illnesses, AMI and ACS.
• Patients with uncontrolled HTN requiring multiple
dosages during the daytime Patients with severe
CHF requiring high doses of diuretics
• Ongoing symptoms such as breathlessness, chest
pain, dizziness, blackouts
• If any women who have any of
the conditions LISTED we
would advise her against
fasting as she will be more
prone to becoming unwell or
collapsing as a result of
dehydration. People with such
potential health consequences
are exempt from fasting.
• Remember that you can
complete your duties by
offering charity or feeding the
poor. If you are unsure, ask
your cardiologist .

20. I have a Fontan circulation, can I fast?
• Women with a Fontan circulation
are particularly prone to becoming
dangerously unwell or collapsing as a
result of dehydration. People who are at
risk from such health problems are exempt
from fasting.
• Remember that you can complete your
duties by offering charity or feeding the
poor. (Fidia )

21. I take regular medication during the day, can I fast?
• It is very important that you continue to
take prescribed medication during
Ramadan.
• If you are prescribed medication which
needs to be taken during the day, then you
are exempt from fasting.
• In some cases, the timing of some
medication can be altered to fit around the
hours of fasting. You must speak to your
doctor
or specialist nurse before altering your
tablets.

22. I have had a recent heart operation, can I fast?
• We would advise anybody undergoing
open heart surgery to not fast until at
least the first clinic visit following her
operation. This usually takes place around
6 weeks after the operation. At this visit,
we can advise you further depending on
your recovery from the operation and
your underlying heart condition.

23. I have congenital heart disease, can I fast?
• If you are pregnant and have
complex congenital heart disease,
you are exempt from fasting.
• If you fast, you could put yourself
and your unborn child at risk.
Remember that you can complete
your duties by offering charity or
feeding the poor.

24. Does a breast feeding
woman have to fast?
No. Islamic law exempts a
breastfeeding mother
from fasting. Missed fasts
will need to be
compensated for by
fasting or Fidia once
breastfeeding has ceased.

25. Does fasting affect breast milk contents
• No significant differences were seen in the content of major nutrients
of milk taken during and after Ramadan.
• There was a slight increase and a slight decrease respectively in the
concentrations of triglycerides and cholesterol after the end of
Ramadan, although these changes were also not significant.

26. REFRENCES
• Ramadan and Congenital Heart Disease a guide for patients .Adult Congenital
Heart Disease Unit Queen Elizabeth Hospital Birmingham
• The effect of Ramadan fasting during pregnancy on perinatal outcomes: a
systematic review and meta-analysis BMC Pregnancy and Childbirth volume 18,
Article number: 421 (2018)
• The cardiac patient during Ramadan and Hajj Journal of the Saudi Heart
Association. Volume 26, Issue 4, October 2014, Pages 212-215
• Ramadan and pregnancy British nutrition foundation
https://www.nutrition.org.uk/
• The cardiac patient in Ramadan. Chamsi-Pasha M, Chamsi-Pasha H. Avicenna J
Med 2016;6:33-8.

27. ----------------------------------------------------------------------------
-----------------------------------------------------------------------------