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It would superficially seem easy to quantify the significance of vaginal bleeding in the first trimester but it is not. Heavy bleeding with clots and pain precede a miscarriage resulting in hospitalisation but many women experience some bleeding early on that is nonrecurrent and is managed in primary care. For such bleeding to be statistically evaluated it requires a large cohort of normal women to book early and be followed through. Hassan et al. from the USA (Obstet Gynecol 2009;114:860–67) enrolled over 4000 women who conceived naturally and documented their risk of miscarriage depending on if they had bleeding or not, the amount of blood loss and whether it was associated with pain or not. Those who bled heavily (similar or more than their normal menses) had three times the risk of miscarrying compared with those who did not bleed. Pain associated with the bleeding increased the risk. Spotting or slight bleeding lasting <2 days without pain carried no greater risk than pregnancies where no bleeding occurred. Considering that a quarter of women have some bleeding in early pregnancy there are many who require appropriate advice. A clear history, as outlined in this paper, plus ultrasonic confirmation of fetal heart presence can accurately guide reassurances that are statistically based.