POSTPARTUM PAPANICOLAU SMEARS:

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POSTPARTUM PAPANICOLAU SMEARS Systematic
Review of the Literature What do the RCTs tell
us? Elizabeth Shaw Assistant
Professor Department of Family Medicine McMaster
University Presented at NAPCRG 2002
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Credit to my colleagues The Evidence-Based
Postpartum Research Group Cheryl Levitt, Liz
Shaw, Janusz Kaczorowski, Sharon Brownlee, Russ
Springate, Murray Enkin, John Sellors, Barbara
Stroskopf, Maria Patriquin Supported by a grant
from the Bureau for Reproductive and Child
Health-Health Canada
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RESULTS

671 studies
140 Articles
Sorted by Topic
66 Articles Other
33 Articles Perineal Pain
41 Articles Breastfeeding
63 Articles
Consensus Reached for Clinical Relevance
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• 63 other

• pap smear
• rubella immunization
• contraception
• postpartum support
• early discharge
• postpartum depression and anxiety
• postpartum medical disorders UTIs,
  haemorrhoids, constipation, weight loss. Anemia
• smoking cessation
• nutritional supplements (other than BF)
• effects of pelvic floor exercises
• effect of early newborn contact

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INTRODUCTION

• Pap screening has reduced deaths due to cervical
  cancer
• Postpartum period-ideal for opportunistic
  screening
• Tradition-Pap at 6 weeks PP ?

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SEARCH RESULTS

• Only one RCT met our inclusion criteria
• Addressed the timing of the PP Pap smear

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METHODOLOGIC QUALITY

• Assessed using the JADAD scale
• Assigns points for randomization, blinding, and
  description of drop-outs
• Scored 2/5
• Randomization process unclear
• Only pathologists were blinded (however not
  overall a detriment to quality)
• PLUS
• Intention to treat
• A priori power calculation

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CLINICAL QUESTION?

• Does the timing of the postpartum Pap smear
  influence the proportion of dysplastic and
  non-dysplastic abnormal results requiring further
  follow-up?

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RESULTS

• 184 women randomized to Pap at 4, 6 or 8 weeks
• Any abnormal smear was followed up at 3 months
• all smears were adequate

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RESULTS
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RESULTS

• Difference in abnormal smears between 4,6 and 8
  weeks was significant (p.36)
• Odds of having a normal Pap
• 6 weeks 2.27 (1.39-3.75)
• 8 weeks 5.20 (1.92-14.07)
• ?50 of the study group failed to show for their
  3 month follow-up

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DISCUSSION

• ? Classification system
• Inflammatory-normal in the Bethesda system
• How many would need to be repeated?
• No difference in atypia or CIN (small
  numbers)
• How many of these smears were necessary in the
  first place?

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CONCLUSION

• Delaying the postpartum Pap smear until 8 weeks
  reduces the number of inflammatory smears
• It is unclear if this reduces the number of
  smears that require further follow-up
• Should low-risk women who are screened regularly
  have a PP pap at all?