Microplastics (MPs) have emerged as a critical environmental challenge in China’s aquatic ecosystems, driven by rapid industrialization and population growth. This review synthesizes recent findings on the abundance, morphology, and polymer types of MPs in China’s freshwater systems (rivers, lakes, reservoirs) and coastal marine environments. Spatial analysis reveals significant variability in MP abundance, ranging from 0.1 items/L in Tibet’s Lalu Wetland to 30.8 items/L in Beijing’s Qinghe River, with polypropylene (PP) and polyethylene (PE) dominating polymer profiles. Coastal regions exhibit distinct contamination patterns, with the Yellow Sea (5.3 ± 2.0 items/L) and the South China Sea (180 ± 80 items/m³) showing the highest MP loads, primarily as fibers and fragments. Fluvial transport, atmospheric deposition, and coastal anthropogenic activities (e.g., fisheries, tourism) are identified as major pathways for marine MP influx. Secondary MPs from degraded plastics and primary MPs from industrial/domestic effluents pose synergistic risks through the adsorption of heavy metals and organic pollutants. Human exposure routes—ingestion, inhalation, and dermal contact—are linked to inflammatory, metabolic, and carcinogenic health outcomes. Policy interventions, including bans on microbeads and non-degradable plastics, demonstrate progress in pollution mitigation. This work underscores the urgency of integrated source control, advanced wastewater treatment, and transboundary monitoring to address MP contamination in aquatic ecosystems.