Effect of ibuprofen versus acetaminophen on postpartum hypertension: a systematic review and meta-analysis of randomized controlled trials

Abstract

Hypertensive disorders of pregnancy (HDP) increase postpartum morbidity and the need for effective pain management, particularly after cesarean delivery. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are effective analgesics but have historically been avoided in women with HDP due to potential blood pressure (BP) elevation. Current guidelines support postpartum NSAID use, but evidence remains limited. This systematic review and meta-analysis aim to evaluate the safety of ibuprofen compared with acetaminophen for postpartum BP control in women with HDP. Following PRISMA guidelines, PubMed, Ovid Medline, and the Cochrane Library were searched for randomized controlled trials (RCTs). Risk of bias was evaluated using the Cochrane RoB2 tool, and meta-analyses were performed using RevMan software. Six RCTs including 535 patients were included. Of these, 269 (50.3%) were assigned to the ibuprofen group, with a mean age of 30.20 ± 6.07 years; and 266 (49.7%) were assigned to the acetaminophen group, with a mean age of 29.14 ± 6.42 years. Pooled analyses showed no significant differences between ibuprofen and acetaminophen in severe postpartum hypertension (OR 1.15, 95% CI 0.75–1.75), systolic BP (MD 1.31 mmHg, 95% CI −1.60 to 4.22), diastolic BP (MD 1.81 mmHg, 95% CI −0.26 to 3.88), mean arterial pressure (MD 0.03 mmHg, 95% CI −1.82 to 1.88), or antihypertensive use (OR 1.00, 95% CI 0.61–1.63). Secondary outcomes, including time to BP control, hospital stay, opioid use, diuresis, and readmission, were also comparable between groups. These findings suggest that short-term postpartum ibuprofen does not increase blood pressure compared with acetaminophen in women with HDP.

Introduction

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal illness and death. Women diagnosed with these conditions during pregnancy often need postpartum antihypertensive treatment and extended monitoring after delivery¹. These women also face a higher likelihood of cesarean delivery, which increases the need for effective postoperative pain management². Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly cyclooxygenase inhibitors, has been shown to raise blood pressure (BP) in healthy, nonpregnant individuals and may interfere with the effectiveness of antihypertensive medications, even after only a few days of use³.

Despite these concerns, NSAIDs remain widely used for managing postpartum and post-cesarean pain in women without hypertension, owing to their proven effectiveness⁴. They outperform acetaminophen in relieving pain from obstetric perineal injuries and also help reduce the need for opioids after cesarean deliveries^4,5. Alternative analgesics also carry risks; for instance, opioids can lead to dependence and may cause central nervous system depression in breastfed newborns. Although acetaminophen offers another non-opioid option that can reduce post-cesarean opioid use, it is not suitable for patients with significantly elevated liver enzymes, a common issue in severe forms of preeclampsia^6,7.

Historically, the American College of Obstetricians and Gynecologists (ACOG) advised against the use of NSAIDs in women with preeclampsia and postpartum hypertension due to theoretical concerns about exacerbating blood pressure⁸. Recent evidence, however, suggests that NSAIDs, including ibuprofen, may be used as part of multimodal postpartum pain management, even in patients with HDP⁹. This shift reflects evolving evidence, but it is important to note that the recommendation was based on only four studies: two retrospective reviews, which found no adverse effect of NSAIDs on postpartum blood pressure, and two randomized controlled trials (RCTs), which showed differing effects of ibuprofen on blood pressure, with one reporting a modest increase in BP but no difference in severe hypertension, and the other showing no meaningful change⁹. These studies are limited by small sample sizes, heterogeneous designs, and variable outcome measures, leaving uncertainty regarding the true safety of NSAIDs. Therefore, a systematic review and meta-analysis of existing RCTs is warranted to synthesize the evidence and provide a more definitive assessment of the comparative safety of ibuprofen versus acetaminophen in this high-risk population.

Materials & methods

Literature review

This review follows the Cochrane review methodology and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines^10,11. It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) in August 2025 (ID: CRD420251134095), and data extraction and analysis were conducted after registration. A comprehensive literature review was initiated in May 2025 using multiple academic databases including PubMed, Ovid Medline, and Cochrane Library with no restrictions on the time frame. The search strategy employed the following keywords in PubMed and Cochrane Library: (Postpartum OR Puerperium) AND (Acetaminophen OR Paracetamol OR N-Acetyl-p-aminophenol) AND (Ibuprofen OR NSAID OR non-steroidal anti-inflammatory drug) AND (Hypertensive disorders OR Preeclampsia OR severe preeclampsia OR gestational hypertension OR hypertension) AND (Randomized controlled trial OR RCT). While these were used in Ovid Medline: Postpartum and Acetaminophen and Ibuprofen) or NSAID) and Hypertensive disorder) or Preeclampsia) and randomized controlled trial).af.

Study selection

The selection and assessment of studies were managed using Rayyan software (https://new.rayyan.ai/)¹². Four authors independently reviewed the titles and abstracts of studies found in the database searches to evaluate their eligibility to potentially meet the qualification requirement for a full review based on defined inclusion and exclusion criteria. In case of any discrepancies, the article is proceeded to a full-text review. The inclusion criteria for the systematic review are as follows: (1) Studies published up to May 2025, without any time restrictions, (2) Studies that included the number of patients assessed, (3) Studies published in English, (4) Studies that compared the use of ibuprofen versus acetaminophen for postpartum BP control in females with HDP, (5) Studies reporting relevant outcomes related to the clinical question, (6) Only randomized controlled trials (RCTs) will be included. Consequently, the exclusion criteria for the study are outlined as follows: (1) Studies published in languages other than English, (2) Studies not comparing the use of ibuprofen versus acetaminophen for postpartum BP control in females with HDP, (3) Studies lacking relevant outcome reporting for the clinical question, (4) Original articles (cross-sectional, prospective cohort, retrospective studies), case-control studies, case series, case report, systematic review, meta-analysis, narrative review, scooping review.

Screening and data extraction

After identifying potentially eligible studies, the full texts of those meeting the inclusion criteria were obtained for further evaluation by two authors independently to confirm their eligibility¹³. Any discrepancies were resolved with input from the lead author. The entire screening process, along with reasons for exclusions, was meticulously documented using a PRISMA flowchart¹¹. Additionally, two authors were tasked with collecting data from the studies included in the review¹³. The data collected from the included studies encompassed several key variables: patient demographics, postpartum BP outcomes and antihypertensive use in ibuprofen versus acetaminophen groups, and postpartum recovery outcomes: hospital stay, opioid use, diuresis, and readmission rates. A third researcher was involved to verify the accuracy of the extracted data. If any critical data was missing, efforts were made to contact the corresponding author for clarification. If contact could not be made or if the missing information remained unavailable, the study was excluded from the analysis¹³.

Bias assessment

Risk of bias was assessed for each included study the Revised Cochrane Risk of Bias (RoB2) for all the included RCTs. Two reviewers independently evaluated the risk of bias, focusing on five predefined domains emphasizing aspects related to the design, implementation, and presentation of the trial¹⁴. Specific inquiries, known as “signaling questions”, were employed within these domains to elicit details relevant to the risk of bias. Subsequently, an algorithm was used to assess these responses, resulting in categorizations of ‘low’ (indicating a low risk of bias across all domains), ‘some concerns’ (suggesting some concern in at least one domain), or ‘high’ (indicating either a high risk in at least one domain or some concerns in multiple domains). A third reviewer subsequently conducts a further evaluation of the assessments.

Statistical analysis

Descriptive statistics were used to summarize the key characteristics of the included studies. When applicable, meta-analyses were conducted using Review Manager (RevMan) software. These analyses computed mean differences (MDs) or odds ratios (ORs), along with 95% confidence intervals, as appropriate, with statistical significance set at a P-value ≤ 0.05. Pooled estimates were calculated using either fixed-effect or random-effects models, depending on the level of heterogeneity, which was assessed using the I² statistic. A random-effects model was applied for substantial heterogeneity (I² > 50%); otherwise, a fixed-effect model was used. When heterogeneity was detected, subgroup analyses were conducted to explore its potential sources. One included trial used a randomized crossover design. Outcomes were reported according to treatment exposure and analyzed using models accounting for treatment period. Although a formal washout period was not incorporated, the original authors did not report evidence suggesting clinically meaningful carryover. Accordingly, treatment-specific estimates were included as reported.

Results

An overview of the reviewed studies’ characteristics

A comprehensive search across PubMed, Ovid Medline, and the Cochrane Library yielded 704 records. After screening and eligibility assessment, six randomized controlled trials (RCTs) including 535 postpartum women with hypertensive disorders of pregnancy (HDP) were included (Table 1, Figure 1). Three studies focused on severe preeclampsia or preeclampsia with severe features^15,17,20, two on gestational hypertension or preeclampsia without severe features^18,19, and one on preeclampsia without specified severity¹⁶. Two included trials^19,20 restricted enrollment to vaginal deliveries, whereas all other trials included mixed delivery modes. All studies used standardized dosing regimens: 600 mg oral ibuprofen or 650 mg oral acetaminophen every 6 hours. One study employed a crossover design¹⁹, while the remaining trials used parallel-group designs. For the crossover trial, outcome denominators (i.e., the number of participants contributing outcome data) reflect exposure-specific data availability rather than mutually exclusive parallel groups.

Table 1.

Characteristics of the included studies.

Article	Country	Study design	Total Participants, N	Participants grouping		Age (years), Mean ± SD (Range)		Type of hypertensive disorder	Regimen of post-partum medications		Vaginal Delivery		Post-partum Magnesium Sulphate		Time from delivery to study medication, h
				Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen		Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen
Blue et al., 201815	USA	Parallel-group RCTs	100	50	50	31.9 ± 5.9	30.5 ± 6.4	Preeclampsia with severe features	600 mg orally every 6 hours	650 mg orally every 6 hours	26	33	NR	NR	NR	NR
Mauwloudi et al., 202416	Iran	Parallel-group RCTs	84	42	42	31.76 ± 5.84	30.42 ± 6.40	pre-eclampsia	600 mg every 6 to 24 hours	650 mg every 6 to 24 hours	26	24	NR	NR	NR	NR
Penfield et al., 202517	USA	Parallel group RCTs	140	70	70	29.9 ± 5.8	29.2 ± 6.5	Severe Pre-eclampsia	600 mg orally every 6 hours	650 mg orally every 6 hours	37	43	48	53	6.4 ± 5.4	6.0 ± 4.6
Penfield et al., 201818	USA	Parallel-group RCTs	61	31	30	28 ± 6	28 ± 5	gestational hypertension or preeclampsia without severe features	600 mg orally every 6 hours	650 mg orally every 6 hours	26	26	NR	NR	3.0 ± 2	3.4 ± 3
Triebwasser et al., 201919	USA	Crossover group RCTs	37	19 (followed by acetaminophen)	18 (followed by ibuprofen)	30.9 ± 6.9	31.1 ± 6.3	Gestational hypertension or preeclampsia without severe features	600 mg orally every 6 hours for 24 hours then crossover to the other drug	650 mg orally every 6 hours for 24 hours then crossover to the other drug	19	18	NR	NR	NR	NR
Vigil-De Gracia et al., 201620	USA	Parallel-group RCTs	113	57	56	28.9 ± 6.0	26.9 ± 6.6	Severe Pre-eclampsia and Superimposed pre-eclampsia			57	56	NR	NR	NR	NR

RCT Randomized controlled trial, USA United States of America, NR Not reported.

Fig. 1.

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart of the reviewed studies.

The diagnostic criteria for hypertensive disorders of pregnancy and, specifically, the definition of severe features varied across the trials. All studies required new-onset hypertension after 20 weeks of gestation. For the trials focusing on severe disease, Penfield et al. (2025)¹⁷ included participants with at least one antepartum measurement of severe hypertension, defined as systolic blood pressure (SBP) ≥160 mmHg or diastolic blood pressure (DBP) ≥105 mmHg, alongside a diagnosis of preeclampsia with severe features per ACOG criteria. Similarly, Blue et al¹⁵. included women with preeclampsia with severe features as defined by ACOG, with exclusions for significant renal or hepatic laboratory abnormalities. Vigil-De Gracia et al²⁰. defined severe preeclampsia as hypertension with proteinuria plus at least one severe criterion, including SBP ≥160 mmHg or DBP ≥110 mmHg, specific symptoms, or HELLP syndrome. In contrast, the study by Mauwloudi et al¹⁶. did not specify severity criteria for its included preeclampsia patients. The remaining two trials focused on non-severe hypertension: Penfield et al. (2019)¹⁸ explicitly excluded patients with severe-range blood pressures or other severe features, and Triebwasser et al¹⁹. enrolled women with gestational hypertension or preeclampsia without severe features, with exclusions based on specific laboratory and symptomatic criteria for severe disease. This variation in diagnostic thresholds, particularly for severe hypertension, is an important source of clinical heterogeneity to consider when interpreting the pooled outcomes, Table 2.

Table 2.

Postpartum Blood Pressure Outcomes and Antihypertensive Use in Ibuprofen versus Acetaminophen Groups.

Article	Severe Postpartum Hypertension, N		Postpartum Systolic blood pressure, mmHg		Postpartum Diastolic blood pressure, mmHg		Any postpartum antihypertensive medication, N		Average postpartum mean arterial blood pressure, Mean ± SD		Time to blood pressure control, hours
	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen
Blue et al., 201815	34/50	31/50	168 ± 16	165 ± 15	99 ± 10	96 ± 10	30/50	26/50	97.6 ± 6.2	97.3 ± 9.1	NR	NR
Mauwloudi et al., 202416	NR	NR	166.92 ± 15.18	164.04 ± 14.15	98.07 ± 9.13	95.02 ± 9.12	NR	NR	NR	NR	56.73 ± 12.48	60.09 ± 10.29
Penfield et al., 202517	27/70	29/70	NR	NR	NR	NR	25/70	28/70	95.7 ± 8.2	95.9 ± 9.5	NR	NR
Penfield et al., 201918	1/31	0/30	NR	NR	NR	NR	2/31	2/30	93 ± 8	93 ± 7	NR	NR
Triebwasser et al., 201919	5/35	7/36	129.1 ± 8.3	129.1 ± 8.5	78.3 ± 6.7	78.6 ± 6.7	1/35	2/36	NR	NR	NR	NR
Vigil-De Gracia et al., 201620	14/57	8/56	NR	NR	NR	NR	NR	NR	NR	NR	56.7 ± 36.8	68.8 ± 43.8

NR Not reported.

Severe postpartum hypertension

Five trials reported the incidence of severe post-partum hypertension requiring antihypertensive therapy^15,17–20. Severe hypertension definitions varied across studies as described in the overview of included studies, but generally referred to SBP ≥160 mmHg or DBP ≥110 mmHg. Two trials used distinct thresholds: Penfield et al. (2025)¹⁷ defined it as SBP ≥160 mmHg or DBP ≥105 mmHg, and Penfield et al. (2019)¹⁸ used a threshold of ≥150/100 mmHg to define persistent hypertension requiring therapy. Pooled analysis showed no difference between ibuprofen and acetaminophen (OR 1.15, 95 % CI [0.75 to 1.75]; P = 0.52; I² = 0 %) (Figure 2).

Fig. 2.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with severe hypertension incidence.

Postpartum systolic and diastolic hypertension

Three studies reported the mean postpartum SBP and DBP^15,16,19. The mean SBP was 156.92 ± 22.13 mmHg among 127 patients in the ibuprofen group, compared to 154.58 ± 20.68 mmHg among 128 patients in the acetaminophen group. Pooled analysis demonstrated no statistically significant difference between the groups (MD 1.31 mmHg, 95% CI [−1.60 to 4.22]; P = 0.38), with no heterogeneity observed (I² = 0%).

Similarly, the mean DBP was 92.98 ± 12.68 mmHg in the ibuprofen group versus 90.78 ± 11.68 mmHg in the acetaminophen group. Pooled analysis again showed no statistically significant difference (MD 1.81 mmHg, 95% CI [−0.26 to 3.88]; P = 0.09), with low heterogeneity across the studies (I² = 39%) (Figure 3 and Figure 4).

Fig. 3.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with average systolic blood pressure (SBP).

Fig. 4.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with average diastolic blood pressure (DBP).

Postpartum mean arterial pressure (MAP)

Mean arterial pressure (MAP) was included as a secondary outcome because it reflects overall arterial perfusion and provides complementary information to systolic and diastolic blood pressure regarding the hemodynamic impact of postpartum analgesic therapy. Three studies reported the mean postpartum MAP values^15,17,18. The mean arterial pressure in the ibuprofen group was 95.77 ± 7.68 mmHg among 151 patients, while in the acetaminophen group it was 95.78 ± 8.99 mmHg among 150 patients. Pooled analysis showed no statistically significant difference between the two groups (MD 0.03 mmHg, 95% CI [−1.82 to 1.88], P = 0.97), with no heterogeneity observed (I² = 0%) (Figure 5).

Fig. 5.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with average mean arterial blood pressure.

Postpartum antihypertensive use

Four studies reported antihypertensive use^15,17–19; 31.2 % of women in each arm received medication. There was no between-group difference (OR 1.00, 95 % CI [0.61 to 1.63]; P = 1.00; I² = 0 %) (Figure 6).

Fig. 6.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with the use of antihypertensive medications.

Time to blood pressure control

Two studies compared time to achieve target BP^16,20. Ibuprofen averaged 56.7 ± 29.0 hours (n = 99) versus 65.1 ± 33.9 hours with acetaminophen (n = 98). The MD was −4.21 hours (95 % CI [−8.86 to 0.44], P = 0.08; I² = 16 %) (Figure 7).

Fig. 7.

Forest Plot of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with the time needed control the blood pressure.

Postpartum recovery outcomes: hospital stay, opioid use, diuresis, and readmission rates

Regarding the length of postpartum hospital stay, two studies reported a mean duration of 2.92 ± 1.28 days in the ibuprofen group and 3.00 ± 1.29 days in the acetaminophen group^15,17. Pooled analysis showed no statistically significant difference (MD −0.03 days, 95% CI [−0.24 to 0.18]; P = 0.77), with no heterogeneity between studies Table 3.

Table 3.

Postpartum Recovery Outcomes: Hospital Stay, Opioid Use, Diuresis, and Readmission Rates.

Article	Length of postpartum hospital stay, days		Opioid use for inadequate pain control (hydrocodone 5 mg)		Diuresis		Readmitted for Severe Hypertension
	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen	Ibuprofen	Acetaminophen
Blue et al., 201815	3.8 ± 1.4	4.0 ± 1.3	NR	NR	NR	NR	1	0
Mauwloudi et al., 202416	NR	NR	NR	NR	NR	NR	3	1
Penfield et al., 202517	2.3 ± 0.7	2.3 ± 0.7	43	40	45	46	2	2
Penfield et al., 201918	NR	NR	9	9	18	22	1	0

Postpartum opioid use for inadequate pain control was reported in two studies, with 51.48% of patients in the ibuprofen group requiring opioids compared to 49% in the acetaminophen group^17,18. Pooled analysis revealed no significant difference (OR 1.12, 95% CI [0.63 to 2.00]; P = 0.69), and no heterogeneity was noted.

Two studies also evaluated the proportion of patients who achieved postpartum diuresis (defined as urine output ≥ 200 mL/hour for four consecutive hours)^17,18. This outcome was achieved by 62.37% of patients in the ibuprofen group and 68% in the acetaminophen group. Pooled analysis again showed no significant difference (OR 0.78, 95% CI [0.44 to 1.40]; P = 0.40), with no heterogeneity.

Finally, four studies reported the rate of hospital readmission due to severe hypertension^15–18. Readmissions occurred in 3.62% of patients in the ibuprofen group versus 1.56% in the acetaminophen group. The pooled OR was 2.03 (95% CI [0.60 to 6.87]; P = 0.25), indicating no statistically significant difference, with no heterogeneity observed (Figure 8).

Fig. 8.

Forest Plots of 95% confidence interval (CI) showing the association of postpartum Ibuprofen versus Acetaminophen with (A) the length of hospital stay, (B) opioid use, (C) diuresis, and (D) readmission rates for severe hypertension.

Risk of bias

Two reviewers independently assessed the risk of bias for eligible RCTs using the RoB 2 Tool for Randomized Trials (Table 4), four of the included RCTs were considered ‘low’ risk of bias, and two were considered to have ‘some concerns’.

Table 4.

Review authors’ judgments about each risk of bias item for each of the included study article.

Article	Bias arising from the randomization process	Bias due to deviations from intended interventions	Bias due to missing outcome data	Bias in measurement of the outcome	Bias in selection of the reported result	Overall RoB
Blue et al., 201815	Low	Some concerns	Low	Low	Low	Some concerns
Mauwloudi et al., 202416	Low	Low	Low	Low	Low	Low
Penfield et al., 202517	Low	Low	Low	Low	Low	Low
Penfield et al., 201918	Low	Low	Low	Low	Low	Low
Triebwasser et al., 201919	Low	Low	Low	Low	Low	Low
Vigil-De Gracia et al., 201620	Low	Some concerns	Low	Some concerns	Low	Some concerns

NR Not reported.

Discussion

Our systematic review and meta-analysis, which includes six randomized controlled trials and a total of 535 postpartum women with HDP, found no statistically significant differences between the use of ibuprofen and acetaminophen in a variety of blood pressure-related outcomes. Specifically, there was no significant difference between the two groups in the incidence of severe postpartum hypertension, SBP and DBP levels, MAP, or need for antihypertensive medications. Similarly, secondary outcomes, including time to achieve target BP, postpartum opioid use, hospital length of stay, diuresis, and hospital readmission, were comparable between the two analgesic regimens. These findings support current ACOG recommendations and suggest that ibuprofen, an NSAID often avoided in hypertensive postpartum patients, does not confer a clinically meaningful increase in blood pressure risk compared to acetaminophen.

Our results are consistent with prior meta-analysis of both randomized and nonrandomized studies found no association between NSAID use and worsening postpartum hypertension in women with HDP, with a pooled relative risk of 1.21 (95% CI 0.89–1.64) for blood pressure ≥150/100 mm Hg and no differences in antihypertensive use, readmission, or opioid requirements²¹. Another synthesis of 10 studies including over 1,600 women showed no increase in MAP, and in fact suggested a small reduction in diastolic pressure with NSAID use, though not of clinical significance²². Observational cohort data likewise confirm that postpartum ibuprofen exposure does not worsen blood pressure or maternal outcomes²³. Isolated reports, such as Vigil-De Gracia et al., observed modest BP increases without differences in severe hypertension, and Markis et al. described rare cases of significant BP elevations^20,24.

Mechanistically, NSAIDs may elevate blood pressure by inhibiting cyclooxygenase-mediated renal prostaglandins (PGE₂, PGI₂), leading to sodium and water retention, reduced renal perfusion, and increased systemic vascular resistance²⁵. In the postpartum period, however, several factors likely attenuate this effect: ibuprofen is usually given at moderate doses for short durations, limiting cumulative prostaglandin inhibition; natural postpartum diuresis mobilizes extracellular fluid, counteracting sodium retention²⁶; and ongoing antihypertensive therapy appears effective despite NSAID use. Together, these mechanisms help explain why clinical studies consistently show no meaningful increase in postpartum blood pressure with ibuprofen.

Our results, supported by observational and synthesized evidence, suggest that ibuprofen can be safely incorporated into postpartum pain management for women with HDP, provided that blood pressure and renal function are monitored. Nonetheless, caution may be warranted in specific subgroups, including women with persistent renal impairment, oliguria, or underlying chronic kidney disease, in whom NSAID-induced alterations in renal hemodynamics could be more pronounced.

This meta-analysis has several strengths. First, it includes only RCTs, which minimizes selection bias and enhances the internal validity of the findings. Second, all included studies used a standardized dosing regimen for both ibuprofen and acetaminophen, improving the comparability across trials. Third, the analysis demonstrated low or no statistical heterogeneity across all outcomes, which increases the reliability of the pooled estimates. Limitations include the relatively small number of studies and participants, which may reduce the power to detect subtle differences, and the exclusion of patients with chronic hypertension or severe comorbidities, limiting generalizability to higher-risk populations. One included trial used a crossover design without a formal washout period, which introduces a theoretical possibility of carryover effects; however, the original analysis accounted for treatment period, and no carryover concerns were reported. Additionally, most studies did not consistently report renal function parameters, precluding a formal assessment of NSAID-associated renal effects. Further research is warranted to evaluate the long-term safety of NSAID use in postpartum women with chronic hypertension, renal impairment, or other comorbidities in large-scale RCTs. Additionally, future trials could explore patient-centered outcomes such as quality of analgesia, breastfeeding satisfaction, and opioid-sparing effects across various clinical settings.

Until such data are available, our findings suggest that routine avoidance of NSAIDs in postpartum women with HDP may not be evidence-based.

Conclusion

Our systematic review and meta-analysis of six randomized controlled trials demonstrate that short-term postpartum use of ibuprofen does not meaningfully increase blood pressure compared with acetaminophen in women with HDP.

Author contributions

Conceptualization, Zainah Abdulbari Alhebshi and Sahar Mohammad Altaweel and Nadiah AlHabardi; Formal analysis, Zainah Abdulbari Alhebshi and Sahar Mohammad Altaweel and Talal Mohammed Zagzoog; Supervision, Zainah Abdulbari Alhebshi and Nadiah AlHabardi; Writing - original draft, Zainah Abdulbari Alhebshi and Sahar Mohammad Altaweel and Talal Mohammed Zagzoog and Raya Tariq Albenayan and Marwah Nasir Ahmad; Writing – review and editing, Zainah Abdulbari Alhebshi and Manar Ali Alzaher and Khaled Waleed Al Assiri and Joudy Anas Moallem and Sarah Fuad Qaid; Data curation, Raya Tariq Albenayan and Marwah Nasir Ahmad and Manar Ali Alzaher and Khaled Waleed Al Assiri; Methodology, Joudy Anas Moallem and Sarah Fuad Qaid. All authors have read and agreed to the published version of the manuscript. Zainah Abdulbari Alhebshi: Conceptualization, Formal analysis, Supervision, Writing - original draft, Writing – review and editing. Sahar Mohammad Altaweel: Conceptualization, Formal analysis, Writing - original draft. Talal Mohammed Zagzoog: Formal analysis, Writing - original draft. Raya Tariq Albenayan: Writing - original draft, Data curation. Marwah Nasir Ahmad : Writing - original draft, Data curation. Manar Ali Alzaher: Writing – review and editing, Data curation. Khaled Waleed Al Assiri: Writing – review and editing, Data curation. Joudy Anas Moallem: Writing – review and editing, Methodology. Sarah Fuad Qaid: Writing – review and editing, Methodology. Nadiah AlHabardi: Conceptualization, Supervision, Writing - review and editing.

Data availability

Data will be available from the correspondence author upon a reasonable request.

Competing interest

The authors declare no competing interests.