The addition of a dose of mifepristone 24 hours before misoprostol administration in the medical management of early pregnancy loss may significantly improve treatment efficacy and should be considered when mifepristone is available. This according to an interim updated Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG) that reviews diagnostic approaches and describes options for the management of early pregnancy loss. The updated ACOG recommendations include:

• In patients for whom medical management of early pregnancy loss is indicated, initial treatment using 800 micrograms of vaginal misoprostol is recommended, with a repeat dose as needed. The addition of a dose of mifepristone (200 mg orally) 24 hours before misoprostol administration in the medical management of early pregnancy loss may significantly improve treatment efficacy and should be considered when mifepristone is available. (Level A recommendation)
• Although the risk of alloimmunization is low, the consequences can be significant, and administration of Rh D immune globulin should be considered in cases of early pregnancy loss, especially those that are later in the first trimester.
• Because of the higher risk of alloimmunization, Rh D-negative women who have surgical management of early pregnancy loss should receive Rh D immune globulin prophylaxis.