Dicle Tıp Dergisi / Dicle Med J (2020) 47 (1) : 74-81

Original Article / Özgün Araştırma

Evaluation Of 8-Hydroxy-2-Deoxyguanosine And Malondialdehyde

Levels In First-Trimester Miscarriage: A Prospective Cohort Study
Reyhan Gündüz1 , Mete Gurol Ugur2 , Neslihan Bayramoğlu Tepe2 , Hüseyin Çağlayan Özcan2 ,
Özcan Balat2 , Sevgi Sari Demir3 , Seyithan Taysi4

1 Dicle University, Faculty of Medicine, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
2 Gaziantep University, Faculty of Medicine, Department of Obstetrics and Gynecology, Gaziantep, Turkey
3 Adana Medline Hospital, Department of Obstetrics and Gynecology, Adana, Turkey
4 Gaziantep University, Faculty of Medicine, Department of Medical Biochemistry, Gaziantep, Turkey
Received: 24.10.2019; Revised: 02.01.2020; Accepted: 22.01.2020

Abstract
Objective: This study was aimed to evaluate 8-hydroxy-2-deoxyguanosine (8-OHdG) and malondialdehyde (MDA) levels
in patients with first trimester miscarriage.
Methods: This prospective cohort study included 35 women, who were diagnosed with miscarriage (patient group) and
35 healthy pregnant women below 14 weeks of gestation (control group), who did not report any complaints. 8-OHdG
levels were measured with a competitive ELISA (Enzyme-Linked ImmunoSorbent Assay) high sensitivity kit and MDA
levels were also measured in both groups.
Results: There wasn’t difference in terms of complete blood count, thyroid-stimulating hormone (TSH), homocysteine
values, parity, age, body mass index (BMI) and gestational age between the groups. Serum 8-OHdG and MDA levels were
significantly higher in the patient group (p=0.001). A moderate positive significant correlation between the gestational
week and MDA values and a weak but significant positive correlation between 8-OHdG values and gestational week were
detected in the patient group.
Conclusion: 8-OHdG and MDA could play a role in the etiopathogenesis of first-trimester miscarriage. However, this role
must be further delineated in large-scaled studies for early diagnosis and management of this condition.
Keywords: Oxidative Stress, malondialdehyde, 8-hydroxy-2-deoxyguanosine, miscarriage, pregnancy.

DOI: 10.5798/dicletip.706022
Correspondence / Yazışma Adresi: Reyhan Gündüz, University of Dicle, School of Medicine, Department of Obstetrics and Gynecology Diyarbakir /
Turkey e-mail: ryhn.gunduz@gmail.com

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Missed Abortuslarda 8-Hidroksi-2-Deoksiguanozin Ve Malondialdehit Seviyelerinin

Değerlendirilmesi: Prospektif Kohort Çalışması

Öz
Amaç: Bu çalışma missed abortusu olan hastalarda 8-hidroksi-2-deoksiguanozin (8-OHdG) ve malondialdehit (MDA)
seviyelerini değerlendirmeği amaçladı.
Metods: Bu prospektif kohort çalışmasına missed abortus tanısı alan 35 kadın (hasta grubu) ve herhangi bir şikayeti
olmayan 14 hafta altı 35 sağlıklı gebe kadın (kontrol grubu) dahil edildi. 8- OHdG seviyeleri yarışmalı sensitivitesi yüksek
ELISA (Enzyme-Linked ImmunoSorbent Assay) kiti ile ölçüldü ve MDA seviyeleri de her iki grupta ölçüldü.
Bulgular: Gruplar arasında tam kan sayımı, tiroid stimulan hormon (TSH), homosistein değerleri, parite, yaş, vücut kitle
indeksi (VKİ) ve gebelik yaşı açısından fark yoktu. Hasta grubunda serum 8-OHdG ve MDA düzeyleri önemli ölçüde daha
yüksek bulundu (p=0.001). Hasta grubunda, gebelik haftası ile MDA değerleri arasında orta derecede pozitif anlamlı bir
korelasyon vardı ve 8-OHdG değerleri ve gebelik haftası arasında zayıf ama anlamlı pozitif bir korelasyon olduğu tespit
edildi.
Sonuç: 8-OHdG ve MDA missed abortus etiyopatogenezinde rol oynayabilir. Ancak, bu durumun erken teşhis ve tedavisi
için geniş ölçekli çalışmalarda bu rol daha fazla tanımlanmalıdır.
Anahtar kelimeler: Oksidatif stres, malondialdehit, 8-hidroksi-2-deoksiguanozin, missed abortus, gebelik.

INTRODUCTION radicals damage cell structures and

Abortion is the premature exit of an immature extracellular matrix elements, but they can also
fetus from the uterus, which is unable to survive cause genetic damage through DNA damage4. 8-
in the extra-uterine environment and hydroxy-2-deoxyguanosine (8-OHdG) is
termination of pregnancy1. The rate of clinically generated by the oxidative modification of
detected fetal loss in the first three months of guanine found in the DNA structure5. It works as
gestation has been reported to be 10-12% in a marker for oxidative DNA damage cause it is
well-documented retrospective and produced when DNA is damaged.
prospective studies .
2 Also, lipid peroxidation (LPO) mediated by free
Although the etiology has not been fully oxygen radicals is an important cause of damage
elucidated for missed abortion in which to the cell membrane. Non-enzymatic LPO
intrauterine fetal demise is not accompanied by directly damages the cell membrane and
bleeding and cervical dilation that occur in indirectly damages other cellular components
other types of abortion, a set of maternal and through the production of reactive aldehydes6-8.
fetal factors can be listed and chromosomal LPO’s final product is Malondialdehyde (MDA)
anomalies, infections, immunologic factors, and used to evaluate the level of oxidative
endocrine disorders, drug use, and damage.
environmental factors are at the top of the list. As far as we investigate, no study investigates
Oxidative stress is thought to affect the the oxidative stress levels end products 8-OHdG
pathophysiology of many diseases. Free radicals and MDA in patients with first-trimester
generated by oxidative stress exert toxic effects miscarriage. Thus, we aimed at investigating the
on carbohydrates, proteins, lipids, and oxidative stress levels end products 8-OHdG
deoxyribonucleic acid (DNA) metabolism3. Free and MDA.

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Gunduz R., Ugur M.G., Tepe N.B., Ozcan H.C., Balat O., Demir S.S., Taysi S.

METHODS obstetric examinations were performed by the

The present study included 35 women that same operator to avoid inter-observer
were diagnosed with first-trimester variability. Demographic data (age, parity,
miscarriage (patient group) between February abortion, and curettage), body mass index
2014 and October 2014 and 35 healthy (BMI) depended on the weight and height
pregnant women (first trimester) below 14 measurement, complaints, LMP, and previous
weeks of gestation (control group) without any history of pregnancy, if any, were recorded.
complaints. The study was carried at the Laboratory tests included blood count
Gynecology Clinics at Şahinbey Hospital of parameters (hemoglobin, white blood cells, and
Gaziantep University Faculty of Medicine, which platelets), fasting blood glucose, human
is a tertiary referral center in Southeastern chorionic gonadotropin (hCG), progesterone,
Turkey serving a population of 6 million people. thyroid-stimulating hormone (TSH), and
The women included in the study were homocysteine levels. CRL was measured on USG
provided information about the study and their in each patient and fetal heart rate was
consents were obtained. The study has received monitored.
approval by the Ethics Committee of Gaziantep 8-OHdG Measurement
University Faculty of Medicine with a decision Northwest kit (Northwest, NWLSS 8-OHdG
number of 448 on December 17th, 2013. ELISA High Sensitivity kit ®, Vancouver,
Exclusion criteria of the study were patients Canada) was used to measure serum 8-OHdG
with an established cause for recurrent levels, which was a marker of oxidative damage.
pregnancy loss such as antiphospholipid Northwest kit is a competitive ELISA (Enzyme-
syndrome, diabetes mellitus, hypothyroidism, linked immunosorbent assay) kit and it is
and other autoimmune or endocrine appropriate to measure oxidative damage in
complications and abortions associated with an DNA molecules in the serum and plasma. ELISA
abnormal karyotype result. was performed at the Department of
The gestational week was calculated according Biochemistry at the Gaziantep University
to the last menstrual period in patients with a Faculty of Medicine9.
regular cycle (LMP) or identified gestational sac MDA Measurement
or crown-rump length (CRL) with transvaginal
ultrasonography. Ultrasound examinations MDA levels were estimated by Hunter et al.10.
were performed with a 7.5-MHz transvaginal After vortexing a mixture of 0.5 ml of 35%
probe (Applio®, Toshiba, Japan). The trichloroacetic acid (TCA) + 0.5 ml serum, 0.5 ml
gestational age was depended on the Tris/HCl buffer (50 mM; pH 7.4) was added and
measurement of CRL in patients in whom the mixed further. And then incubated at room
last menstrual period was unclear or there was temperature for 10 minutes. After adding one
more than the one week difference between ml of 0.75% thiobarbituric acid (TBA) in 2 M
calculations depended on LMP and Na2SO4 heating procedure was performed to
ultrasonography (USG). Fetal heart rate was the mixture at 100°C for 45 min. After cooling
detected in all patients in the control group and this mixture, 1 ml of 70% TCA was instilled. And
no abnormal USG finding was observed. There then it was vortexed and centrifuged at 950 × g
was an embryo in the miscarriage group, but no for 10 minutes. The absorbance of the
fetal heart rate was observed. supernatant was detected at 530 nm. Total TBA-
reactive materials were enounced as MDA,
A detailed medical history was obtained upon using a molar extinction coefficient for MDA of
admission in the two groups, and systemic and
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1.56×105 cm–1M–1. Biochemical Table I. Comparison of the groups according to age, gestational
age, parity, BMI, and laboratory values.
measurements were achieved at room
Control
temperature using a Cecil CE 3041 Patient Group
Group
spectrophotometer (Cambridge, UK). Variable p*
(n=35)
(n=35)
Statistical Analysis
Age 30.46 ± 6.93 30.37 ± 6.96 0.959#
The student's t-test was used to compare
numeric variables with normal distribution and Gestational
8.5 ± 1.84 9.09 ± 1.79 0.169#
the Student t-test (for normal data) and Mann- Age (week)

Whitney U (for non-normal data) tests were Parity 2( 0-7) 1 (0-4) 0.325§
used to compare numerical variables between
BMI (kg/m2) 24.35 ± 2.55 24.15 ± 2.78 0.755#
the groups. The chi-square test was used to the
relationship between categorical variables. Hemoglobin 12.52 ±
12.86 ± 1.36 0.293#
(g/dl) 1.36
Correlations between variables were displayed
Leukocyte 8.188 ± 8.890 ±
by Superman's rank correlation analysis. A p- (x103/ml) 2592.72 2848.58
0.285#

value of less than 0.05 was understood Platelets 264.028 ± 247.371 ±

0.361#
statistically significant. Statistical analysis which (x106/ml) 82228.69 68719.41

was performed with Statistical Package for the TSH (uIU/ml) 1.18 ± 0.82 1.42 ± 0.61 0.169#

Social Sciences for Windows (SPSS, version 11.5, Homocysteine 8.89 ± 6.56 9.85 ± 7.49 0.571#
Chicago, IL, USA) was used to data analysis. (umol/L)
Progesterone
26.2 ± 13.25 15.69 ± 11.55 0.001#
RESULTS (ng/ml)
A total of 70 women (35 patients and 35 hCG 55876.11± 19773.71±
0.001#
controls) that did not have any of the exclusion (mIU/ml) 39794.62 19447.07
criteria were included in this study. The 8-OHdG
parameters of complete blood count, TSH and 6.31 ± 2.61 10.01 ± 2.44 0.001#
(ng/ml)
homocysteine values, age, parity, gestational
MDA
age, BMI values based on height and weight 8.72 ± 5.27 14.39 ± 6.05 0.001#
(µmol/L)
measurements, weren’t significantly different
BMI: Body mass index
between groups and results are shown in Table
I. TSH: Thyroid-stimulating hormone
hCG: Human chorionic gonadotropin
The mean level of 8-OHdG in the patient group
8-OHdG: 8-hydroxy-2-deoxyguanosine
was higher than controls and this situation was
statistically significant (p< 0.001) (Table I). MDA: Malondialdehyde
Also, mean levels of MDA were significantly * A p-value below 0.05 was considered as significant
higher in the patient group in comparison to There wasn’t significant correlation in the
controls (p<0.001) (Table I). Mean levels of intragroup analysis of serum 8-OHdG, MDA and
progesterone were significantly higher in homocysteine levels in the control group. A
controls in comparison to patients (p<0.001) moderate positive significant correlation
(Table I). Mean hCG levels were also between a gestational week and MDA values
significantly higher in controls than patients (r=0.443, p=0.008) (Figure 1) and a significant
(p<0.001). positive correlation between 8-OHdG values
and gestational week were detected ın the
patıent group (r=0.392, p=0.02) (Figure 2).
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Gunduz R., Ugur M.G., Tepe N.B., Ozcan H.C., Balat O., Demir S.S., Taysi S.

correlation between 8-OHdG values and

gestational week ın the patıent group.
Spontaneous loss of a pregnancy can be
classified clinically using different methods.
Commonly used subgroups include abortus
imminence, abortus insipient, incomplete and
complete abortions. Miscarriage is a condition
in which intrauterine fetal demise is not
accompanied by bleeding and cervical dilation
that occur in other types of abortion11.
Miscarriage can show a relationship with
various etiologic factors. The factors such as
chromosomal anomalies, malformations,
Figure 1. Correlation of MDA to the gestational week in both immunologic factors, endocrine disorders, and
groups. environmental factors may be the cause of
MDA: Malondialdehyde miscarriage; however, investigations toward
detecting the etiology of miscarriage fail to
elucidate the underlying physiopathologic
mechanisms in half of the cases12-13. Oxidative
stress is currently a hot topic and some authors
suggest that it may have a key role in etiology
and pathogenesis of various obstetric
conditions14-20.
In a study by Maisonneuve et al.14, oxidized low-
density lipoprotein and MDA levels were
evaluated as the marker of oxidative stress in
cord blood of dichorionic twin pairs, with one
co-twin with intrauterine growth restriction
(IUGR). There were more abnormal Doppler
ultrasound findings, more vascular disease and
Figure 2. Correlation of 8-OHdG to the gestational week in both higher levels of MDA were detected in the IUGR
groups.
group compared to the controls14. These
8-OHdG: 8-hydroxy-2-deoxyguanosine
substances affect membrane permeability and
lead to excessive intracellular Ca+2
DISCUSSION accumulations. Dysfunctional cell membrane
leads to cell swelling and cellular death. MDA
This study aimed to evaluate 8-OHdG and MDA measurement in biologic materials is used as
levels in patients with first-trimester the indicator of lipid peroxide levels.
miscarriage. Serum 8-OHdG and MDA levels
were significantly higher in the patient group One study evaluated MDA and antioxidant
(p=0.001). There was a moderate positive enzyme levels in sera of preeclamptic women in
significant correlation between a gestational the second and third trimesters of pregnancy15.
week and MDA values in the patient group and The levels of MDA were higher in the
there was a weak but significant positive preeclamptic group compared to the controls,
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particularly in the third trimester, while correlation between a gestational week and 8-
superoxide dismutase levels were lower15. MDA OHdG values in the patient group.
could affect the etiology and pathogenesis of The increased 8-OHdG levels in the urine were
miscarriage. related with an increased incidence of GDM in
A recent study compared 8-OHdG and 8- pregnant women before twenty weeks of
isoprostane levels between women having full- gestation18. The present study found higher
term and preterm babies based on the serum 8-OHdG levels and fasting blood glucose
assumption that maternal oxidative stress could in the patient group compared to the control
be important in preterm delivery and the group. Due to the exclusion of patients with
results suggested that these parameters could GDM and similar systemic disorders and based
be important in understanding the mechanisms on the findings of the study by Qui et al.18,
of preterm delivery16. monitoring of these patients for the
The studies that evaluated MDA and 8-OHdG development of GDM in the forthcoming weeks
levels to understand the relationship between of gestation may be suggested.
oxidative stress and prematurity and birth In the study by Peter Stein et al.19, the
weight found significantly higher 8-OHdG and relationship between the urinary levels of the
MDA levels in cord blood of preterm babies with markers of oxidative stress in the early periods
low birth weight17. of pregnancy and the course of pregnancy, and
Several studies have reported that markers of low 8-OHdG levels were suggested to be
oxidative DNA damage and oxidative stress, 8- relevant with low birth weight and shorter
OHdG, and MDA, respectively, could affect the duration of pregnancy. One of the limitations of
etiology and pathogenesis of the different this study is that the evaluation of urinary 8-
diseases. One study was reported that preterm OHdG levels was not planned. Also, the
low-birth-weight newborns were higher 8- relatively small number of patients and controls
OHdG and MDA levels in the patient group than may be criticized.
controls17. Another study, they found maternal In the study by Onan et al.21, ıt has been shown
urinary 8-OHdG levels were higher than that the lipid peroxidation levels may be a more
controls and increase in early pregnancy sensitive indicator of intrapartum distress than
urinary 8-OHdG levels were as relevant with results of acid-base studies.
increased gestational diabetes mellitus (GDM) Progesterone is a crucial hormone for
risk19. Therefore, they evaluated their levels in maintenance of a normal pregnancy and serum
patients with first-trimester miscarriage and progesterone levels below 5 ng/mL is a useful
reported that levels of both are significantly sign for non-viable pregnancies but, was unable
increased when compared with controls and to differentiate ectopic pregnancy from
most of them quantified the products of lipid abnormal intrauterine pregnancy20.
peroxidation (mainly MDA) and contrasted Progesterone levels in patients with
them with the activity of antioxidant enzymes miscarriage in the our study were lower
or antioxidants levels. In the results obtained, compared to the subjects in the control group
they reported that there is an imbalance (p< 0.001) as expected. Also, hCG levels were
between the high amount of free radicals and lower in the miscarriage group as an expected
insufficient antioxidant activity. In this study, consequence of a decreased number of viable
we found 8-OHdG levels in the patient group chorion villi and an associated decrease in hCG
were higher than the controls. In addition, we
showed that there was a significant positive
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Gunduz R., Ugur M.G., Tepe N.B., Ozcan H.C., Balat O., Demir S.S., Taysi S.

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