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Urbaniak SK, Boguszewska K, Szewczuk M, Kaźmierczak-Barańska J, Karwowski BT. 8-Oxo-7,8-Dihydro-2'-Deoxyguanosine (8-oxodG) and 8-Hydroxy-2'-Deoxyguanosine (8-OHdG) as a Potential Biomarker for Gestational Diabetes Mellitus (GDM) Development. Molecules 2020; 25:molecules25010202. [PMID: 31947819 PMCID: PMC6982778 DOI: 10.3390/molecules25010202] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/30/2019] [Accepted: 01/01/2020] [Indexed: 12/12/2022] Open
Abstract
The growing clinical and epidemiological significance of gestational diabetes mellitus results from its constantly increasing worldwide prevalence, obesity, and overall unhealthy lifestyle among women of childbearing age. Oxidative stress seems to be the most important predictor of gestational diabetes mellitus development. Disturbances in the cell caused by oxidative stress lead to different changes in biomolecules, including DNA. The nucleobase which is most susceptible to oxidative stress is guanine. Its damage results in two main modifications: 8-hydroxy-2′-deoxyguanosineor 8-oxo-7,8-dihydro-2′-deoxyguanosine. Their significant level can indicate pathological processes during pregnancy, like gestational diabetes mellitus and probably, type 2 diabetes mellitus after pregnancy. This review provides an overview of current knowledge on the use of 8-hydroxy-2′-deoxyguanosineand/or 8-oxo-7,8-dihydro-2′-deoxyguanosine as a biomarker in gestational diabetes mellitus and allows us to understand the mechanism of 8-hydroxy-2′-deoxyguanosineand/or 8-oxo-7,8-dihydro-2′-deoxyguanosine generation during this disease.
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Castilla-Peon MF, Medina Bravo PG, Sánchez-Urbina R, Gallardo-Montoya JM, Soriano-López LC, Coronel Cruz FM. Diabetes and obesity during pregnancy are associated with oxidative stress genotoxicity in newborns. J Perinat Med 2019; 47:347-353. [PMID: 30676004 DOI: 10.1515/jpm-2018-0201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/23/2018] [Indexed: 01/22/2023]
Abstract
Objective To compare the level of oxidative deoxyribonucleic acid (DNA) damage (genotoxicity) between the offspring of mothers with and without diabetes diagnosed during pregnancy and its association with maternal body mass index (BMI). Methods We measured 8-hydroxy-deoxyguanosine (8-OH-dG), a marker of DNA oxidative damage, in venous umbilical cord plasma from newborns of mothers with (n=34) and without (n=56) diabetes diagnoses obtained during pregnancy. Two markers of oxidative stress - namely, nitric oxide degradation products (NOx) and total glutathione (GSH) - were quantified in both mothers and newborns. The effects of BMI, glycated hemoglobin (HbA1c), age and delivery mode were also analyzed. Results Newborns of mothers with diabetes during pregnancy exhibited higher levels of 8-OH-dG than those of mothers without diabetes (P<0.001). The other markers of oxidative stress were also higher in both mothers with diabetes and their newborns, with the exception of NOx in the mothers. The association of diabetes with 8-OH-dG was independent of other analyzed factors. Conclusion The offspring of mothers with diabetes during pregnancy are born with increased genotoxicity than the offspring of mothers without diabetes. BMI and HbA1c display an independent association with 8-OH-dG, particularly in the offspring of mothers not diagnosed with diabetes.
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Affiliation(s)
| | | | - Rocío Sánchez-Urbina
- Research Unit in Congenital Heart Diseases, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Juan Manuel Gallardo-Montoya
- Research Unit in Renal Diseases, Centro Médico Nacional "Siglo XXI", Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Luis César Soriano-López
- Research Unit in Congenital Heart Diseases, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Fausto Moisés Coronel Cruz
- Materno-Fetal Medicine Unit, Obstetrics and Gynecology Department, Hospital General de México Eduardo Liceaga O.D., Mexico City, Mexico
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Corrêa MDS, Gelaleti RB, Bento GF, Damasceno DC, Peraçoli JC. DNA damage in Wistar Kyoto rats exercised during pregnancy. Acta Cir Bras 2017; 32:388-395. [PMID: 28591368 DOI: 10.1590/s0102-865020170050000008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/10/2017] [Indexed: 01/21/2023] Open
Abstract
Purpose: To evaluate DNA damage levels in pregnant rats undergoing a treadmill exercise program. Methods: Wistar Kyoto rats were allocated into two groups (n= 5 animals/group): non-exercise and exercise. The pregnant rats were underwent an exercise protocol on a treadmill throughout pregnancy. Exercise intensity was set at 50% of maximal capacity during maximal exercise testing performed before mating. Body weight, blood pressure and glucose levels, and triglyceride concentration were measured during pregnancy. At day 10 post-natal, the animals were euthanized and maternal blood samples were collected for DNA damage. Results: Blood pressure and glucose levels and biochemical measurements showed no significant differences. Increased DNA damage levels were found in exercise group compared to those of non-exercise group (p<0.05). Conclusion: The exercise intensity protocol used in the study might have been exhaustive leading to maternal increased DNA damage levels, demonstrating the relevance of an adequate protocol of physical exercise.
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Affiliation(s)
- Mikaela da Silva Corrêa
- Fellow Master degree, Postgraduate Program in Ginecology, Obstetrics and Mastology, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Scientific, intellectual, conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Rafael Bottaro Gelaleti
- Fellow PhD degree, Postgraduate Program in Ginecology, Obstetrics and Mastology, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Scientific and intellectual content of the study, analysis and interpretation of data, technical procedures, statistics analysis, manuscript preparation, critical revision
| | - Giovana Fernanda Bento
- Graduate student, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Scientific and intellectual content of the study, acquisition of data, technical procedures
| | - Débora Cristina Damasceno
- Full Professor, CNPq Researcher Followship 2, Postgraduate Program in Ginecology, Obstetrics and Mastology, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Scientific, intellectual, conception and design of the study; analysis and interpretation of data; statistics analysis; manuscript preparation; critical revision; final approval
| | - José Carlos Peraçoli
- Full Professor and Head, CNPq Researcher Fellowship 2, Postgraduate Program in Ginecology, Obstetrics and Mastology, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Scientific, intellectual, conception and design of the study; analysis and interpretation of data; critical revision; final approval
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Moreli JB, Santos JH, Lorenzon-Ojea AR, Corrêa-Silva S, Fortunato RS, Rocha CR, Rudge MV, Damasceno DC, Bevilacqua E, Calderon IM. Hyperglycemia Differentially Affects Maternal and Fetal DNA Integrity and DNA Damage Response. Int J Biol Sci 2016; 12:466-77. [PMID: 27019630 PMCID: PMC4807165 DOI: 10.7150/ijbs.12815] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 01/13/2016] [Indexed: 12/28/2022] Open
Abstract
Objective: Investigate the DNA damage and its cellular response in blood samples from both mother and the umbilical cord of pregnancies complicated by hyperglycemia. Methods: A total of 144 subjects were divided into 4 groups: normoglycemia (ND; 46 cases), mild gestational hyperglycemia (MGH; 30 cases), gestational diabetes mellitus (GDM; 45 cases) and type-2 diabetes mellitus (DM2; 23 cases). Peripheral blood mononuclear cell (PBMC) isolation and/or leukocytes from whole maternal and umbilical cord blood were obtained from all groups at delivery. Nuclear and mitochondrial DNA damage were measured by gene-specific quantitative PCR, and the expression of mRNA and proteins involved in the base excision repair (BER) pathway were assessed by real-time qPCR and Western blot, respectively. Apoptosis was measured in vitro experiments by caspase 3/7 activity and ATP levels. Results: GDM and DM2 groups were characterized by an increase in oxidative stress biomarkers, an increase in nuclear and mitochondrial DNA damage, and decreased expression of mRNA (APE1, POLβ and FEN1) and proteins (hOGG1, APE1) involved in BER. The levels of hyperglycemia were associated with the in vitro apoptosis pathway. Blood levels of DNA damage in umbilical cord were similar among the groups. Newborns of diabetic mothers had increased expression of BER mRNA (APE1, POLβ and FEN1) and proteins (hOGG1, APE1, POLβ and FEN1). A diabetes-like environment was unable to induce apoptosis in the umbilical cord blood cells. Conclusions: Our data show relevant asymmetry between maternal and fetal blood cell susceptibility to DNA damage and apoptosis induction. Maternal cells seem to be more predisposed to changes in an adverse glucose environment. This may be due to differential ability in upregulating multiple genes involved in the activation of DNA repair response, especially the BER mechanism. However if this study shows a more effective adaptive response by the fetal organism, it also calls for further studies to determine the limit of this response that definitely changes the fate of a fetus under these conditions of cellular stress.
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Affiliation(s)
- Jusciele B Moreli
- 1. Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University / UNESP, São Paulo, Brazil
| | - Janine H Santos
- 2. Laboratory of Molecular Carcinogenesis, National Institute of Environmental Health Sciences / NIEHS, North Carolina, USA
| | - Aline Rodrigues Lorenzon-Ojea
- 3. Department of Cell and Developmental Biology, Institute of Biomedical Sciences, University of São Paulo / USP, São Paulo, Brazil
| | - Simone Corrêa-Silva
- 1. Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University / UNESP, São Paulo, Brazil.; 3. Department of Cell and Developmental Biology, Institute of Biomedical Sciences, University of São Paulo / USP, São Paulo, Brazil
| | - Rodrigo S Fortunato
- 4. Laboratory of Molecular Radiobiology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro / UFRJ, Rio de Janeiro, Brazil
| | - Clarissa Ribeiro Rocha
- 5. DNA Repair Laboratory, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo / USP, São Paulo, Brazil
| | - Marilza V Rudge
- 1. Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University / UNESP, São Paulo, Brazil
| | - Débora C Damasceno
- 1. Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University / UNESP, São Paulo, Brazil
| | - Estela Bevilacqua
- 3. Department of Cell and Developmental Biology, Institute of Biomedical Sciences, University of São Paulo / USP, São Paulo, Brazil
| | - Iracema M Calderon
- 1. Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University / UNESP, São Paulo, Brazil
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Moreli JB, Santos JH, Rocha CR, Damasceno DC, Morceli G, Rudge MV, Bevilacqua E, Calderon IMP. DNA damage and its cellular response in mother and fetus exposed to hyperglycemic environment. BIOMED RESEARCH INTERNATIONAL 2014; 2014:676758. [PMID: 25197655 PMCID: PMC4147359 DOI: 10.1155/2014/676758] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 07/16/2014] [Accepted: 07/16/2014] [Indexed: 02/02/2023]
Abstract
The increased production of reactive oxygen species (ROS) plays a key role in pathogenesis of diabetic complications. ROS are generated by exogenous and endogenous factors such as during hyperglycemia. When ROS production exceeds the detoxification and scavenging capacity of the cell, oxidative stress ensues. Oxidative stress induces DNA damage and when DNA damage exceeds the cellular capacity to repair it, the accumulation of errors can overwhelm the cell resulting in cell death or fixation of genome mutations that can be transmitted to future cell generations. These mutations can lead to and/or play a role in cancer development. This review aims at (i) understanding the types and consequences of DNA damage during hyperglycemic pregnancy; (ii) identifying the biological role of DNA repair during pregnancy, and (iii) proposing clinical interventions to maintain genome integrity. While hyperglycemia can damage the maternal genetic material, the impact of hyperglycemia on fetal cells is still unclear. DNA repair mechanisms may be important to prevent the deleterious effects of hyperglycemia both in mother and in fetus DNA and, as such, prevent the development of diseases in adulthood. Hence, in clinical practice, maternal glycemic control may represent an important point of intervention to prevent the deleterious effects of maternal hyperglycemia to DNA.
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Affiliation(s)
- Jusciele Brogin Moreli
- Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University (UNESP), SP, Brazil
| | - Janine Hertzog Santos
- Laboratory of Molecular Carcinogenesis, National Institute of Environmental Health Sciences (NIEHS), NC, USA
| | - Clarissa Ribeiro Rocha
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo (USP), SP, Brazil
| | - Débora Cristina Damasceno
- Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University (UNESP), SP, Brazil
| | - Glilciane Morceli
- Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University (UNESP), SP, Brazil
| | - Marilza Vieira Rudge
- Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University (UNESP), SP, Brazil
| | - Estela Bevilacqua
- Department of Cell and Developmental Biology, Institute of Biomedical Sciences, USP, University of São Paulo, São Paulo, Brazil
| | - Iracema Mattos Paranhos Calderon
- Graduate Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, São Paulo State University (UNESP), SP, Brazil
- Department of Obstetrics and Gynecology, Botucatu Medical School, São Paulo State University (UNESP), Distrito de Rubião Jr. s/n, 18618-000 Botucatu, SP, Brazil
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Damasceno DC, Sinzato YK, Lima PH, de Souza MS, Campos KE, Dallaqua B, Calderon IM, Rudge MV, Volpato GT. Effects of exposure to cigarette smoke prior to pregnancy in diabetic rats. Diabetol Metab Syndr 2011; 3:20. [PMID: 21851636 PMCID: PMC3170573 DOI: 10.1186/1758-5996-3-20] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 08/18/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of cigarette smoke exposure before pregnancy on diabetic rats and their offspring development. METHODS Diabetes was induced by streptozotocin and cigarette smoke exposure was conducted by mainstream smoke generated by a mechanical smoking device and delivered into a chamber. Diabetic female Wistar rats were randomly distributed in four experimental groups (n minimum = 13/group): nondiabetic (ND) and diabetic rats exposed to filtered air (D), diabetic rats exposed to cigarette smoke prior to and into the pregnancy period (DS) and diabetic rats exposed to cigarette smoke prior to pregnancy period (DSPP). At day 21 of pregnancy, rats were killed for maternal biochemical determination and reproductive outcomes. RESULTS The association of diabetes and cigarette smoke in DSPP group caused altered glycemia at term, reduced number of implantation and live fetuses, decreased litter and maternal weight, increased pre and postimplantation loss rates, reduced triglyceride and VLDL-c concentrations, increased levels of thiol groups and MDA. Besides, these dams presented increased SOD and GSH-Px activities. However, the increased antioxidant status was not sufficient to prevent the lipid peroxidation observed in these animals. CONCLUSION Despite the benefits stemming from smoking interruption during the pregnancy of diabetic rats, such improvement was insufficient to avoid metabolic alterations and provide an adequate intrauterine environment for embryofetal development. Therefore, these results suggest that it is necessary to cease smoking extensive time before planning pregnancy, since stopping smoking only when pregnancy is detected may not contribute effectively to fully adequate embryofetal development.
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Affiliation(s)
- Débora C Damasceno
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Yuri K Sinzato
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Paula H Lima
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Maricelma S de Souza
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
- Pharmacology Department, University of Marilia_UNIMAR, Marilia, São Paulo State, Brazil
| | - Kleber E Campos
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
- Institute of Biological and Health Sciences, University Center of Araguaia, Mato Grosso Federal University (UFMT), Mato Grosso, Brazil
| | - Bruna Dallaqua
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Iracema M Calderon
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Marilza V Rudge
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
| | - Gustavo T Volpato
- Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Gynecology and Obstetrics, Laboratory of Experimental Research in Gynecology and Obstetrics, São Paulo State, Brazil
- Institute of Biological and Health Sciences, University Center of Araguaia, Mato Grosso Federal University (UFMT), Mato Grosso, Brazil
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de Souza MDSS, Sinzato YK, Lima PHO, Calderon IMP, Rudge MVC, Damasceno DC. Oxidative stress status and lipid profiles of diabetic pregnant rats exposed to cigarette smoke. Reprod Biomed Online 2010; 20:547-52. [PMID: 20153698 DOI: 10.1016/j.rbmo.2010.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 08/05/2009] [Accepted: 12/07/2009] [Indexed: 11/24/2022]
Abstract
This study aimed to evaluate the oxidative stress status and the concentrations of triglycerides, cholesterol and total proteins of pregnant rats exposed to the association of diabetes and cigarette smoke. Female Wistar rats were randomly distributed in four experimental groups, according to presence or not of diabetes and the exposure or not to cigarette smoke. Diabetes was induced by streptozotocin (40 mg/kg i.v.) and exposure to cigarette smoke was for 30 min, twice a day, for 2 months. At day 21 of pregnancy, blood was collected for total protein, triglyceride, cholesterol and oxidative stress determinations. Data were analysed by ANOVA followed by Student-Newman-Keuls test (P<0.05). The association of diabetes and exposure to cigarette smoke was related to the incidence of hypertriglyceridaemia, and this result was due to the severe diabetes and not to exposure to smoke. There was no alteration to protein metabolism in pregnant rats. Diabetes and cigarette smoke exposure led to the activation of the antioxidant system in an attempt to detoxify the organism in face of high lipid peroxidation, which can be characterized by the determination of reactive substances to thiobarbituric acid.
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Affiliation(s)
- Maricelma da Silva Soares de Souza
- Laboratory of Experimental Research of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP/Univ Estadual Paulista, São Paulo State, Brazil
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de Souza MDSS, Lima PHO, Sinzato YK, Rudge MVC, Pereira OCM, Damasceno DC. Effects of cigarette smoke exposure on pregnancy outcome and offspring of diabetic rats. Reprod Biomed Online 2009; 18:562-7. [PMID: 19401000 DOI: 10.1016/s1472-6483(10)60135-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A total of 52 female Wistar rats were distributed into four groups: non-diabetic (G1) and diabetic (G2) exposed to filtered air; non-diabetic (G3) and diabetic (G4) exposed to cigarette smoke. Diabetes was induced by streptozotocin (40 mg/kg bodyweight, i.v.). Rats were exposed, for 30 min, to filtered air (control) or to tobacco smoke generated from 10 cigarettes, twice a day, for 2 months. At the end of the 2-month exposure, at day 21 of pregnancy, each rat was anesthetized and humanely killed for laparotomy. Uterine horns were exposed for reproductive performance analysis, fetal and placental weights and placental index. Maternal and fetal data were analysed by ANOVA followed by the Student Newman-Keuls test. Fetal weight classification was assessed by Fisher's exact test. Diabetes and cigarette smoke caused placentomegaly (G4 = 0.65 +/- 0.19 g versus G1 = 0.49 +/- 0.03 g, P < 0.05), increased placental index (G4 = 0.13 +/- 0.03 versus G1 = 0.09 +/- 0.00, P < 0.05) and small fetus rates for pregnancy age (G4 = 88% versus G1 = 23.2%, P < 0.05). These observations show the importance of encouraging pregnant women to attempt cessation of smoking.
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Affiliation(s)
- Maricelma da Silva Soares de Souza
- Laboratory of Experimental Research of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Botucatu Medical School, São Paulo State University, São Paulo, Brazil
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