Women over the age of 40 years are at a higher risk of early pregnancy complications such a miscarriage or ectopic pregnancy. They are also more likely to have pre-existing medical conditions which further increase their risk of early pregnancy pathology, for example, previous pelvic inflammatory disease leading to a tubal ectopic, or uncontrolled diabetes increasing the risk of a miscarriage. Women in this age group are also more likely to have conceived through fertility treatment, and may present with complications of this, such as multiple pregnancy or ovarian hyperstimulation syndrome. A woman’s history of assisted reproductive technology and pre-existing subfertility is significant not only in accurately dating the pregnancy but also with regards to the psychological impact in case of a poor outcome. Early pregnancy units have become well established in most hospitals as a dedicated department providing specialist early pregnancy care. This chapter provides an overview of the optminal management of the first trimester of pregnancy for women over 40 and the management of the common conditions.