Vaginal bleeding during early pregnancy is a common condition. It is associated with an underlying abnormality, which often is a serious cause requiring emergency management. Clinical diagnosis in such cases is mostly nonconclusive, and ultrasound (both abdominal and transvaginal), a valuable and easily available tool, is required to identify the cause and guide the clinician in choosing the appropriate line of management. With the objective of evaluating patients presenting with vaginal bleeding in early pregnancy, this study was conducted in the Department of Obstetrics and Gynecology, Mahatma Gandhi Medical College and Hospital, Jaipur, for a period of 1.5 years. All cases with first-trimester vaginal bleeding were selected, and clinical diagnosis was confirmed by ultrasonography (USG). A total of 728 patients with first-trimester bleeding were evaluated. The most common clinical diagnosis was threatened abortion. Out of 505 cases of threatened abortion diagnosed clinically, ultrasound confirmed threatened abortion in 340 cases only. In the rest of these cases, the diagnosis was complete abortion in 24, missed abortion in 85, tubal ectopic in 7, and in one case, a vesicular mole was diagnosed. Eleven cases of arteriovenous malformation and eight cases of scar pregnancy, both requiring specific management, were observed only by ultrasound. The study highlights the importance of USG, which plays an important role in evaluation of the causes of first-trimester bleeding, prognosticate and predict the status of abnormal pregnancies.