In recent years, the proportion of advanced maternal age pregnancies has increased, accompanied by a rising detection rate of uterine fibroids during pregnancy. Current evidence suggests an association between uterine fibroids complicating pregnancy and an elevated risk of miscarriage, with fibroid location and number potentially serving as key determinants. The underlying mechanisms may involve reduced endometrial receptivity secondary to alterations in uterine cavity anatomy, local hemodynamic disturbances such as impaired perfusion, and dysregulation of the inflammatory and immune microenvironment. Clinically, preconception evaluation should incorporate fibroid classification, size, number, and their impact on uterine cavity configuration. Submucosal fibroids that distort the uterine cavity may be considered for removal prior to conception. During pregnancy, women with uterine fibroids should be managed as high-risk, with serial surveillance and timely management of related complications. This review aims to synthesize the most up-to-date evidence regarding the relationship between uterine fibroids during pregnancy and miscarriage risk, elucidate potential mechanisms, and propose individualized preconception and antenatal management strategies based on fibroid type, size, and number, thereby informing clinical risk assessment and standardized prevention and management.