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Is there a role for oral misoprostol in labor induction for prelabor rupture of membranes at term?

BMC Pregnancy and Childbirth volume 25, Article number: 467 (2025) Cite this article

Abstract

Background

Most patients with pre-labor rupture of membranes (PROM) enter labor spontaneously at term. However, maternal and neonatal complications increase with prolonged PROM. Induction of labor (IOL) is therefore often recommended, but the optimal agent is still debated. Low-dose oral misoprostol (OM) is safe, effective, cheap, and easy to administer. However, there is little data regarding its role in PROM at term.

Objective

To determine the safety and efficacy of OM compared to Intravenous Oxytocin for IOL for PROM at term.

Study design

A cohort study compared the perinatal outcomes of patients with unfavorable Bishop scores who underwent IOL for PROM at term with OM compared to IV Oxytocin. Patients were allocated to OM or Oxytocin based on : patient preference, physician discretion, and bed availability in the antenatal or labor ward. The primary outcome was the rate of vaginal delivery within 24 h of membrane rupture. Other outcomes included duration from PROM and induction until delivery, duration of labor ward admission, mode of delivery, indications for cesarean delivery, postpartum hemorrhage (PPH), suspected chorioamnionitis, placental abruption, blood transfusion, shoulder dystocia, postpartum readmission, APGAR score < 7 at 5 min, umbilical artery pH < 7.1, neonatal intensive care unit admission, GBS disease, infectious or respiratory morbidity, hypoglycemia, jaundice and necrotizing enterocolitis. Outcomes were analyzed individually and as composite adverse maternal and neonatal outcomes.

Results

493 patients (62.4%) patients underwent IOL with OM. Outcomes were compared to 296 (37.6%) patients undergoing induction with IV Oxytocin. Patients receiving OM had a reduced chance of vaginal delivery within 24 h (76.3% vs. 87.5% OR 0.6 (0.4–0.9, p < 0.001 but not within 48 h (93.7% vs. 95.2% OR 0.7 (0.4–1.4), p = 0.2). They had a longer interval from PROM (1190 ± 26.7 min vs. 856.9 ± 33.6 min, p < 0.001) (95% CI 40–60%) and induction to delivery (671.6 ± 26.1 min vs. 453 ± 27.5 min, p < 0.001) but a shorter labor ward admission (233.7 ± 10.5 min vs. 471 ± 13.8 min, p < 0.001), with no increased risk of maternal and neonatal complications. Restricting the analysis to nuliparas, there was a significant reduction in the rate of vaginal delivery within 24 h with OM(59.4% vs. x85.8% OR 0.2 [0.1–0.5], p < 0.001).

Conclusion

IOL with OM for term PROM is effective, leading to a high rate of vaginal delivery without associated increased risks. It may prolong delivery duration but reduces labor ward time, making it a valuable option to discuss during patient counseling.

Peer Review reports

Introduction

In most women, the onset of labor at term is heralded by regular uterine contractions. Nevertheless, approximately 10% of women experience pre-labor rupture of membranes (PROM), where the fetal membranes rupture before the onset of contractions [1]. Most women with PROM will enter labor spontaneously within 48 h of membrane rupture [2]. However, there is robust evidence that the risk of maternal and neonatal complications increases proportionally with the duration from PROM to delivery [3, 4]. Furthermore, compared to expectant management, induction of labor is associated with a reduced interval from PROM to delivery and, consequently, a reduced risk of adverse outcomes such as chorioamnionitis, endometritis, neonatal sepsis, neonatal intensive care unit (NICU) admission, without an increase in the risk of cesarean delivery [1, 2]. These findings have led many physicians and the American College of Obstetrics and Gynecology (ACOG) to recommend labor induction rather than expectant management for term PROM [5].

The optimal method of labor induction in term PROM has been the subject of many studies [6,7,8]. The benefits of IV Oxytocin are primarily a greater control over dosing; however, the need for continuous monitoring in the delivery room has been associated with higher risks of obstetric intervention and may burden health resources [9]. Prostaglandin E2 (PGE2) has also been studied, but compared to prostaglandin E1 (PGE1), it has higher costs and can’t be stored at room temperature [10, 11]. Several randomized controlled trials have explored misoprostol (PGE1, Cytotec) as an alternative method for inducing labor in cases of term PROM [12,13,14,15,16], and a recent meta-analysis has determined that misoprostol is both a safe and effective option for labor induction in patients experiencing PROM at term [7]. However, the meta-analysis encompassed studies with small sample sizes, frequently lacking sufficient power to determine the primary outcomes conclusively. Low-dose oral misoprostol (PGE1) has re-emerged as a compelling alternative to IV oxytocin for labor induction due to its efficacy at cervical ripening, ease of storage, and administration, resulting in significant cost benefits [17]. Additionally, in the setting of PROM, the oral route may be preferred as it avoids the introduction of a foreign body to the vagina, which has been associated with an increased risk of infection [18] and is also the preferred route of drug administration for many patients [19].

This study aims to compare the safety and efficacy of labor induction with oral misoprostol versus IV oxytocin in patients presenting with PROM at term and to determine the effect of induction agents on maternal and neonatal outcomes.

Materials and methods

A retrospective cohort study was conducted at a single university-affiliated medical center between 2012 and 2023. The study group comprised patients who presented to the obstetric emergency room with PROM at ≥ 37 ± 0 weeks of gestation and an unfavorable bishop score (< 6). Patients were excluded from the study if they had a bishop score ≥ 6, were in active labor, initiated induction of labor > 12 h after PROM or had contraindications to expectant management of PROM, e.g., meconium or blood-stained amniotic fluid, evidence of chorioamnionitis, non-reassuring fetal status or maternal indications for induction of labor or intrauterine fetal death. Other exclusion criteria included a previous cesarean delivery, parity greater than 5, multiple pregnancy, or any contraindication to vaginal delivery.

The study group was split into two groups. Group 1 included patients who underwent induction of labor with oral misoprostol. Group 2 consisted of patients who underwent induction of labor with IV oxytocin. Patients were allocated to OM or Oxytocin based on a combination of factors including patient preference, physician discretion, and bed availability in the antenatal or labor ward. The decision regarding the timing at which induction was initiated was also based on patient and physician preference and bed availability. Providing that there were no maternal or fetal contraindications to expectant management, patients were offered immediate induction or the option of waiting for labor to commence spontaneously for a period of 12–24 h. While there were no formal amendments to the departmental protocol for managing PROM at term during the study period, over time, there was a tendency to increase the emphasis on prompt induction, reduce the duration of expectant management, and encourage induction with IV oxytocin rather than OM.

Patients in our department receive oral misoprostol while admitted to the antenatal ward. The protocol for labor induction with oral misoprostol (PGE1, Cytotec) involves the administration of an initial 50-micrograms dose of misoprostol orally. This dose is repeated every four hours until active labor develops, up to a maximal dose of 300 micrograms. Patients receiving oral misoprostol are transferred from the antenatal ward to the delivery suite if any of the following events occur: A nonreassuring fetal heart rate tracing, suspected tachysystole, active labor, latent phase with a strong desire for epidural analgesia, or active bleeding.

The IV oxytocin induction protocol at our center involves administering 2.5 mu/min of IV oxytocin, which is increased at increments of 2.5 mu/min every 20 min until a maximum of 22.5 mu/min.

The study groups were compared for the following baseline demographic characteristics: Maternal age, parity, chronic hypertension and diabetes, maternal Group B Streptococcus (GBS) carrier status, epidural use, and gestational age at delivery.

The primary outcome was vaginal delivery within 24 h of membrane rupture. Secondary outcomes included vaginal delivery within 48 h of membrane rupture, vaginal delivery within 24 and 48 h from initiation of labor induction, mode of delivery, time from PROM to delivery, time from IOL until delivery, time spent in labor and delivery room, indications for cesarean delivery, postpartum hemorrhage (PPH), suspected chorioamnionitis (defined as patients who received intrapartum antibiotics for suspected chorioamnionitis based on the presence of fever or fetal tachycardia), placental abruption, blood product transfusion, shoulder dystocia, and postpartum readmission. Neonatal secondary outcomes included APGAR score < 7 at 5 min, umbilical artery pH < 7.1, duration of NICU admission, early-onset GBS disease, neonatal sepsis, any respiratory morbidity, hypoglycemia, jaundice and necrotizing enterocolitis.

These outcomes were analyzed as individual parameters and as composite adverse maternal outcomes (CAMO), which was comprised of PPH, suspected chorioamnionitis, placental abruption, shoulder dystocia, postpartum readmission/ composite adverse neonatal outcome (CANO) included neonatal APGAR score < 7 at 5 min, umbilical artery pH < 7.1, duration of NICU admission, early-onset GBS disease, neonatal sepsis, respiratory morbidity, hypoglycemia, jaundice, and necrotizing enterocolitis.

Data was collected from the computerized patient database. Demographic data and maternal and neonatal outcomes for each group were compared. Data analysis and graphical representation were performed using GraphPad Prism version 10.0.2 (GraphPad Software, La Jolla, California, USA). Data were analyzed using Students t-test, Mann Whitney U tests, and Chi-Square tests.

Multivariate logistic regression was performed for the primary outcome of vaginal delivery within 24 h of membrane rupture. Multivariate linear regressions were performed to determine the time from PROM till delivery. Models were adjusted for maternal age, parity, gestational age at delivery, neonatal birthweight, epidural use, and GBS status. Kaplan–Meier curves were drawn to demonstrate the proportion of women delivered at each hour after membrane rupture in both groups. A planned subgroup analysis was performed to evaluate the effect of the induction agent on the outcomes mentioned above in primiparous and multiparous patients. Differences were considered significant when the p-value was less than 0.05. The study was approved by our local institutional review board (Approval number MHMC-0025-21), and informed consent was waived due to the study’s retrospective design.

Results

During the study period, there were 106,066 deliveries at our center. 14,646 patients presented to the maternal assessment unit with PROM at term. Of those, 789 met the inclusion criteria for our study. There were 493 patients (62.4%) in Group 1 (misoprostol induction) and 296 (37.6%) patients in Group 2 (oxytocin induction).

Patients who underwent induction of labor with oral misoprostol were younger, less likely to be colonized with GBS or have epidural analgesia but more likely to be nulliparous than those undergoing induction with oxytocin; however, there were no other clinically significant differences between the groups in the rate of medical comorbidities (Table 1).

Table 1 Demographic characteristics of the study groups
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With regards to the primary outcome, patients undergoing induction of labor with oral misoprostol had a significantly reduced chance of vaginal delivery within 24 h of membrane rupture (76.3% vs. 87.5% OR 0.6 (0.4–0.9, p < 0.001), even after controlling for confounders such as age, parity, epidural use, maternal GBS colonization, and neonatal birth weight. However, there was no significant difference in the rate of vaginal delivery within 48 h of membrane rupture (93.7% vs. 95.2% OR 0.7(0.4–1.4), p = 0.2). (Table 2)

Table 2 Maternal and obstetric outcomes across the study groups
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Patients receiving misoprostol had a longer interval from PROM to delivery (1190 ± 26.7 min vs. 856.9 ± 33.6 min, p < 0.001) (95% CI 40–60%) (Table 2 ± 3 and Fig. 1) as well as induction to delivery (671.6 ± 26.1 min vs. 453 ± 27.5 min, p < 0.001). However, they had a significantly shorter duration in the labor ward (233.7 ± 10.5 min vs. 471 ± 13.8 min, p < 0.001).Factors associated with increased time from membrane rupture until delivery in patients undergoing induction are described in Table 3.

Fig. 1
figure 1

Kaplan–Meier curve showing time from membrane rupture to delivery by according to method of induction

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Table 3 Factors associated with the time from membrane rupture until delivery in patients undergoing induction
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Patients induced with oral misoprostol had a significantly reduced risk of experiencing PPH (2.0% vs. 4.0% OR 0.49 [0.2–1.1] p = 0.02) compared to those who received IV oxytocin. Other than that, there were no significant differences in the rate of maternal outcomes, including placental abruption, chorioamnionitis, shoulder dystocia, cesarean delivery, or postpartum readmission or the composite adverse maternal outcome (4.9% vs. 6.0%, 0.8 [0.4–1.4] p = 0.2). There were also no between-group differences in the risk of adverse neonatal outcomes, including 5 min Apgar score < 7, Umbilical artery pH < 7.1, NICU admission, respiratory or infective morbidity, hypoglycemia, jaundice, NEC or the composite adverse neonatal outcome (1.2% vs. 2.3%, 0.9 [0.2–3.1] p = 0.4) (Table 4). The mode and indications for delivery in the cohort are presented in Table 5.

Table 4 Neonatal outcomes across the study groups
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Table 5 Indications for cesarean delivery
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A sub-group analysis of 322 nulliparous patients also demonstrated significantly lower rates of vaginal delivery within 24 h (59.44% VS 85.8%, p < 0.0001) but not within 48 h (88.9% vs. 94.3%, p = 0.06) of membrane rupture in patients receiving misoprostol, with no associated increase in cesarean delivery overall(8.7% vs. 4.7% OR 1.9 [0.7–5.3] p = 0.1) or composite adverse maternal or neonatal outcome (6.9% vs. 11.3%, 0.6 [0.3–1.3], p = 0.09) (1.9% vs. 1.9%,1.0 [0.2–5.4], p = 0.49) (Table 6). When restricting the analysis to multiparous patients, there were no significant differences between the groups in the rate of vaginal delivery within 24 (89.5% vs. 90.5% OR 0.9 [0.5–1.7], p = 0.4) and 48 h, respectively (97.5% vs. 95.8% OR 1.7 [0.6–4.7], p = 0.2). Nor were there any differences in the rate of cesarean delivery (1.1% vs. 2.1% OR 0.5 [0.1–2.3], p = 0.19), composite adverse maternal (3.3% vs. 3.2%, 1.0 [0.4–2.9], p = 0.5) or neonatal outcome (0.7% vs. 2.6%, 0.3 [0.1–1.4], p = 0.06) (Table 7).

Table 6 Subgroup analysis - maternal and obstetric outcomes across the study groups in primiparas
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Table 7 Subgroup analysis - maternal and obstetric outcomes across the study groups in multiparas
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Discussion

Principal findings

Our findings suggest an association between the use of oral misoprostol for labor induction in cases of membrane rupture at term and longer durations from both membrane rupture and induction initiation until delivery, compared to those receiving IV oxytocin. Whilst in nulliparas, induction with oral misoprostol was associated with a reduction in the rate of vaginal delivery within 24 h, this was not the case in multiparas. Induction with oral misoprostol was associated with a decrease in the duration of admission to the labor ward, lower rates of PPH, and no increase in adverse maternal or neonatal outcomes. Despite induction of labor being the recommended management for term PROM, there is no consensus in the literature regarding the optimal induction method in these cases. Oral misoprostol (PGE1) has many benefits as an induction agent due to its efficacy, low cost, ease of storage, acceptability to patients, and in the case of PROM, avoidance of vaginal examinations. Data regarding the outcomes of oral misoprostol compared to IV oxytocin for induction of labor for PROM at term is limited to small RCTs, which have failed to demonstrate the superiority of one agent over the other [20,21,22,23,24,25,26,27]. Furthermore, the heterogeneous study populations, variations in oxytocin and misoprostol dosing protocols, and measured study outcomes make comparing studies difficult. Studies conducted on this subject are summarized in Table 8 [20,21,22,23,24,25,26,27].

Table 8 Studies evaluating maternal and neonatal outcomes in patients receiving oral misoprostol vs. oxytocin for IOL in term PROM
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Our findings that patients who are induced with low-dose oral misoprostol are significantly less likely to have a vaginal delivery within 24 h of membrane rupture compared to those undergoing induction with IV oxytocin contrast with the findings of Crane et al. [21] and Ahmed et al. [27] who demonstrated no difference in the rate of vaginal delivery within 24 h with the induction method. In addition, our finding from the multivariate regression analysis, which revealed an independent effect of oral misoprostol in prolonging the interval from PROM to delivery (Fig. 1; Table 3)was in line with some [20, 21, 25] but not all studies [20, 23]. The discrepancy in findings might be attributable to underlying differences between the studies, including study populations, dosing and administration protocols, and criteria used to select induction methods. At our center, patients undergo induction with oral misoprostol on the antenatal ward, with non-continuous monitoring, allowing full ambulation until active labor. The ratio of nursing staff to patients is significantly lower than that in the delivery ward, where patients undergo induction with IV oxytocin. In addition, physicians must review cardiotocography (CTG) tracings and confirm each repeat dose of oral misoprostol before administration. These factors are likely to contribute to delays in administering oral misoprostol doses, affecting the interval from membrane rupture until delivery in this group.

It is also biologically plausible that the efficacy of oral misoprostol is attenuated in cases of membrane rupture (PROM) due to a shared mechanism of action between endogenous and exogenous prostaglandins. Misoprostol, a synthetic analog of prostaglandin E1, softens the cervix while prompting uterine contractions [28, 29]. In addition, membrane rupture results in a significant release of endogenous prostaglandins both locally and systemically, which are also responsible for the initiation of labor [30]. Consequently, in the event of membrane rupture,, where there has already been a significant release of local and systemic prostaglandins, the incremental benefit of exogenous prostaglandins may be limited. In contrast, adding an oxytocin receptor agonist, operating through a distinct mechanism, could offer more significant benefits. Indeed, multiple lines of evidence have illustrated that utilizing a combination of amniotomy and oxytocin for induction, instead of employing each method independently, decreases the duration from induction to delivery [31,32,33]. This highlights the advantages and potential synergistic effects of utilizing a dual approach for labor induction. The multivariate analyses (Table 3) also demonstrated independent effects of parity and regional anesthesia on the duration from PROM to delivery. These effects were not surprising since nulliparity has long been associated with longer durations of spontaneous and induced labor [27, 34,35,36,37] and indeed was demonstrated in the subgroup analyses of this study (Tables 6 and 7). In addition, high-quality studies have also demonstrated an effect for epidural analgesia on the prolongation of labor (38, 39).

That being said, irrespective of the induction agent used, vaginal delivery rates in our study remained high overall. Furthermore, in multiparas, there was no difference in the rate of vaginal delivery after 24 h of PROM, and by 48 h this was true also for nulliparas. Consistent with findings from other studies [20,21,22,23, 25,26,27], this prolonged duration did not correlate with an increase in adverse outcomes, including infectious complications, suggesting that, despite disadvantages regarding the length of labor.

Indeed, we were surprised to note that despite the increased duration from PROM to delivery, there was no increase in the rate of suspected chorioamnionitis (1.8% vs. 1.4% p = 0.3) in this group, despite reports linking a prolonged duration of PROM to an elevated risk of chorioamnionitis (3, 4). There are several explanations for this. Although the difference in time from PROM to delivery was statistically significant between the two groups, the median difference in duration was only 5.5 h (Table 2). This relatively small time difference may not be clinically significant for chorioamnionitis risk as the threshold for increased infection risk may be higher than this observed difference. Furthermore, patients with risk factors for chorioamnionitis, such as prolonged PROM or unknown GBS status, received prophylactic antibiotics according to our departmental protocol which significantly reduces the rates of chorioamnionitis overall [40] In that way, the protective effect of antibiotics may have offset any potential increase in infection risk due to longer delivery times. Patients undergoing induction with oral misoprostol were less likely to be colonized with GBS. This, too, might have mitigated the potential risk of chorioamnionitis associated with the increased interval from ROM to delivery in this group, since GBS colonization increases the risk for chorioamnionitis [41]. Lastly, the small sample size may have prevented the study from being able to detect significant differences in the risk of chorioamnionitis between the groups.

Clinical implications

In this study, we demonstrated that patients who opted for induction with oral misoprostol spent less time in the labor and delivery ward. Reduced labor ward durations have advantages for both patients and their caregivers. For the patient, a short duration of admission to the labor ward, unconfined to a bed, continuous fetal monitoring, and an oxytocin infusion have been linked to lower intervention rates during labor [42]. This also enables the patient to move and ambulate in the early stages of labor, an approach associated with lower intervention rates, improved neonatal outcomes [43], easier non-pharmacological pain management techniques, and a more positive birth experience [44]. Indeed, Crane et al. have demonstrated that patients receiving oral misoprostol compared to IV oxytocin report higher levels of patient satisfaction, and it is certainly possible that some patients might opt for a longer interval to delivery if it allows them greater mobility and greater freedom of movement.

The induction method also has ramifications on the allocation of healthcare resources and occupancy in the labor ward. Extended labor inductions on the labor ward are costly [45] due to the increased presence of highly qualified personnel and the necessity for more frequent monitoring and intervention. Reducing the duration of admission to the labor ward during induction might allow hospitals to allocate healthcare resources more efficiently; moreover, in busy delivery centers, shorter durations on the labor ward could ease the management of bed capacity by reallocating bed space in the delivery ward to patients in active labor who require it the most. Finally, the convenience of storage (no refrigeration required) and administration reduces resource demands, making oral misoprostol a desirable choice, especially in low-resource settings. Overall oral misoprostol stands as an excellent alternative candidate as an induction agent. Its other notable benefits ought to be considered when considering the method of labor induction.

Research implications

Multiple factors, including patient safety, efficacy, cost-effectiveness, patient expectations and preferences for their care, should be considered when implementing management protocols. To determine the safety and efficacy of different induction methods, a large-scale randomized controlled trial (RCT) with sufficient statistical power to detect differences in clinically important outcomes should be conducted to determine the optimal induction method for term PROM. In addition to evaluating maternal and neonatal clinical outcomes, trials must include patient-reported outcomes and patient satisfaction metrics to obtain a more holistic appreciation of the impacts of any intervention.

As an example, within the scope of this study, it is possible that some patients would prefer to spend less time in the labor ward due to the freedom of movement associated with this, at the expense of a longer delivery and vice versa. There is compelling data highlighting the relationship between birth experience and maternal-infant bonding [46] and long-term mental health [47, 48]. Addressing these factors in future studies will allow patients to make informed and personalized decisions about their care.

Strengths and limitations

To our knowledge, this study represents the largest cohort of patients who underwent induction of labor with oral misoprostol for PROM at term. As such, it contributes valuable data to address a common clinical scenario for which limited evidence currently exists. Due to our large population, we were also able to perform a subgroup analysis to analyze the effect of parity on the outcomes listed. In addition, we evaluated and compared a wide range of maternal and neonatal outcomes to a group of patients undergoing induction with IV oxytocin, a common alternative to oral misoprostol for induction of labor.

Our study was limited by its retrospective nature and the inherent biases associated with this, particularly the provider-dependent decision-making process leading to differences in the characteristics of the study groups. Patients receiving oral misoprostol were more likely to be nulliparous, younger, and less likely to be colonized by GBS. This pattern may reflect a clinical bias towards administering oral misoprostol to patients expected to have longer induction times, particularly nulliparas. This approach could be motivated by a desire to avoid prolonged occupation of delivery ward beds and extended periods of continuous monitoring. Conversely, patients with GBS colonization were more likely to be induced with oxytocin, possibly due to a preference for a more active induction process aiming to reduce the delivery duration and minimize the risk of chorioamnionitis associated with prolonged labor in GBS-positive patients. To address this bias, we adjusted regression models for key confounding variables, including maternal age, parity, gestational age at delivery, neonatal birthweight, epidural use, and GBS status. We also conducted subgroup analyses to examine the effects separately in nulliparous and multiparous women, which helped to isolate the impact of parity on our outcomes. We acknowledge that a randomized controlled trial would be the ideal study design to address this question definitively.

We also recognize that cervical status at the initiation of induction, is a crucial detail that could significantly influence our outcomes. Our failure to include this variable is a significant limitation. Unfortunately, we did not have patients individual Bishop scores available to us but patients were only included in the study if their cervical dilation was < 3 cm at the time of induction, such that, the study groups were both comprised of patients with poor Bishop scores.

Lastly, due to our study’s low rate of adverse outcomes, we were underpowered to detect significant clinical differences in important clinical outcomes such as chorioamnionitis and neonatal sepsis.

Conclusions

Patients who undergo labor induction for PROM at term using oral Misoprostol exhibit a high chance of achieving vaginal delivery without any increased risks of maternal or neonatal morbidity. While this induction method may extend the delivery duration, it decreases the time spent in the labor ward, which has significant benefits for patients and their healthcare providers. This information should be integrated into patient counseling to support informed decision-making about labor induction options, enhancing the overall care and management for expectant mothers with PROM at term.

Data availability

The data that support the findings of this study are available on request from the corresponding author [M.L]. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author [M.L] with the permission of the local institutional review board -Mayanei Hayeshua Medical Center.

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Acknowledgements

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Funding

There was no funding for this study.

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Authors and Affiliations

  1. Maayanei Hayeshua Medical Center, Bnei Brak, Israel

    Adi Ashkenazi Katz, Lior Kashani-Ligumsky, Ariel Many & Miriam Lopian

  2. School of Medicine, Tel Aviv University, Tel Aviv, Israel

    Adi Ashkenazi Katz, Lior Kashani-Ligumsky, Ariel Many & Miriam Lopian

  3. Sheba Medical Center, Tel Hashomer, Israel

    Ella Segal

  4. Department of Obstetrics and Gynaecology, Mayanei Hayeshua Medical Center Bnei Brak, Bnei Brak, Israel

    Miriam Lopian

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Contributions

A.AK: First draft Manuscript writing, data analysisE.S: Data collection, data analysis Review of the final version of the manuscript L.K: Data collection, Review of the final version of the manuscriptA.M - Project development, Review of the final version of the manuscriptM.L - Project development, data collection, data analysis, first draft manuscript writing, review of the final version of the manuscript.

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Correspondence to Miriam Lopian.

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Ethics approval and consent to participate

In accordance with the Declaration of Helsinki, the local ethical review board at Mayanei Hayeshua Medical Center approved the study (Approval number MHMC-0025-21). Due to the retrospective nature of this study, the Mayanei Hayeshua Medical Center ethics board waived consent to participate.

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Not applicable.

Competing interests

The authors declare no competing interests.

The findings from this study were presented as a poster session at the Society for Maternal and Fetal Health Global Congress on September 26th, 2024, in Rome, Italy.

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Katz, A.A., Segal, E., Kashani-Ligumsky, L. et al. Is there a role for oral misoprostol in labor induction for prelabor rupture of membranes at term?. BMC Pregnancy Childbirth 25, 467 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-024-07040-7

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BMC Pregnancy and Childbirth

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