For women with medical conditions the routine physical and emotional challenges of pregnancy are amplified by fluctuating symptoms and difficult treatment decisions that must balance risks and benefits to both mother and unborn child. Choosing the best option is rarely straightforward when drugs are needed. A discussion to consider the treatment options well before conception is helpful.
Valproate is a good example. An effective treatment for epilepsy, it is also licensed for bipolar disorder and, in some countries, migraine. But its teratogenic potential is well established, and there is no current agreement on the appropriate regulation of the drug in women who may become pregnant.
Recently, European and UK drug regulators strengthened their advice on use of valproate in this context12: it should not be used unless a comprehensive “pregnancy prevention programme is followed.” Our editorialists Angelika Wieck and Sarah Jones explain that the European Commission will soon decide whether to make these recommendations legally binding (doi:10.1136/bmj.k1609). “A positive decision would be desirable and looks likely,” they say.
The related analysis by Heather Angus-Leppan and Rebecca Liu (doi:10.1136/bmj.k1609) considers alternative approaches to valproate regulation, ranging from a ban to restricted availability. They emphasise that women should not be denied the human right to make their own decisions after fully informed discussion: “Banning valproate imposes less effective treatment for some female patients than for other people with a similar life threatening or serious condition, without their consent.”
Good communication is central to good healthcare, and talking to colleagues is high on Margaret McCartney’s agenda this week (doi:10.1136/bmj.k1602). She reflects on a time when colleagues communicated directly about patients, unlike today when referrals can be rejected simply for being on the wrong form. “People make the NHS; and people, in the end, are the only way to make it work” she says.
As our countdown continues to the NHS’s 70th birthday, McCartney finds it “hard to escape the feeling that the NHS is in terminal decline.” A new series of articles called Provocations will examine how to halt that decline and explore the NHS’s future direction. We kick off this week with Mark Britnell (doi:10.1136/bmj.k1685), who argues that health leaders must engage with the productivity debate. Productivity “is about harnessing the talents of NHS staff” and is not to be feared, he says. Do join the debate online.

中文翻译：

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良好的沟通是良好照顾的关键

对于患有医疗状况的女性，由于症状的波动和难以做出的治疗决定（必须平衡对母婴的风险和收益），怀孕对身体和情感的常规挑战更为严重。当需要药物时，选择最佳选择很少是一件容易的事。在受孕之前进行讨论以考虑治疗方案是很有帮助的。
丙戊酸就是一个很好的例子。它是癫痫病的有效治疗方法，也被许可用于躁郁症和某些国家的偏头痛。但是，它的致畸潜力已得到充分证实，目前尚无关于可能怀孕妇女适当控制该药物的协议。
最近，欧洲和英国的药物监管机构加强了在这种情况下使用丙戊酸盐的建议12：除非遵循全面的“预防怀孕方案”，否则不应使用丙戊酸盐。我们的社论专家Angelika Wieck和Sarah Jones解释说，欧盟委员会将很快决定是否使这些建议具有法律约束力（doi：10.1136 / bmj.k1609）。他们说：“一个积极的决定将是可取的，而且看起来很可能。”
Heather Angus-Leppan和Rebecca Liu（doi：10.1136 / bmj.k1609）进行的相关分析考虑了丙戊酸盐调节的替代方法，从禁令到限量供应。他们强调，在充分知情的讨论之后，不应剥夺妇女做出自己决定的权利：“在未征得其同意的情况下，丙戊酸对某些女性患者的治疗效果要比对其他具有类似生命威胁或严重状况的患者有效。
良好的沟通对于良好的医疗保健至关重要，在本周的玛格丽特·麦卡特尼（Margaret McCartney）的议事日程中，与同事进行对话非常重要（doi：10.1136 / bmj.k1602）。她回想起当时同事直接就患者进行交流的情况，与今天不同的是，转诊可以仅仅因为格式错误而被拒绝。“人们制定了NHS；最终，人是使它起作用的唯一方法。”她说。
随着我们的倒计时持续到NHS的70岁生日，麦卡特尼发现“很难逃脱NHS处于衰落状态的感觉”。一系列名为“挑衅”的新文章将探讨如何制止这种下降，并探讨NHS的未来方向。我们本周与Mark Britnell（doi：10.1136 / bmj.k1685）共同拉开序幕，他认为卫生领导人必须参与生产力辩论。他说，生产力“是在利用NHS员工的才能”，因此不必担心。参加在线辩论。