Vaginal bleeding in the first trimester of pregnancy is a very common problem. One in four women will experience vaginal bleeding during pregnancy and this accounts for 1‐2% of all Emergency Room visits. The high circulating levels of estrogen and progesterone in pregnancy bring about several changes that can cause bleeding or spotting. Any woman of reproductive age who presents with vaginal bleeding in the first trimester with or without pain is at risk for ectopic pregnancy. There are many reasons for vaginal bleeding in the first trimester other than ectopic pregnancy or impending miscarriage. Once early pregnancy failure has been confirmed, treatment options include dilatation and curettage (D&C), manual vacuum aspiration, expectant management, or medical management using misoprostol. Through the integration of history, physical examination, hCG levels and transvaginal ultrasound examination, a physician can usually arrive at the etiology of first trimester vaginal bleeding.