Red degeneration of uterine leiomyomas during pregnancy is a distinct emergency occurring in the second and third trimesters, which may lead to various adverse maternal and fetal outcomes in severe cases. It is primarily characterized by acute abdominal pain and fever. Due to its atypical presentation, differentiation from various acute abdominal conditions is required. A comprehensive evaluation of the red degeneration is essential, involving dynamic assessment and stratified management based on gestational age, fibroid characteristics (e.g., size, number, location), clinical symptoms, and the patient′s overall condition. Conservative treatment should be the first-line approach. If conservative treatment proves ineffective, myomectomy may be considered. The feasibility of vaginal delivery should be thoroughly assessed, as uterine leiomyomas are not an absolute indication for cesarean section. For patients eligible for vaginal delivery, close monitoring during labor is necessary, with timely intervention when indicated to reduce adverse maternal and neonatal outcomes.