The Successful Management of an Adult Patient With Unrepaired Tetralogy of Fallot for Caesarian Section: A Case Report From South Africa.

Tetralogy of Fallot (TOF) is a congenital heart defect characterized by four interlinked cardiac anomalies, leading to cyanosis and significant health risks if left untreated. We present the management and outcome of an adult patient with unrepaired TOF at 34 weeks of pregnancy at a central Johannesburg hospital. Uncorrected TOF in adulthood, especially in the late stages of pregnancy, is rare, presenting challenges for both the mother and baby. This case report outlines our successful management strategy, highlighting the importance of careful hemodynamic stability. The primary goal in managing this complex case was to prevent significant changes in systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). We diligently avoided triggers for worsening right-sided pressures and aimed to maintain haemodynamic stability and therefore optimise oxygen delivery and minimise blood loss and dehydration. Our approach focused on preventing a worsening right-to-left shunt, which exacerbates hypoxia and haemodynamic instability. Regarding the anaesthetic technique, we discuss the advantages and disadvantages of both general and regional anaesthesia. While there is no gold standard, the choice should be individualized based on the patient's condition and treating unit practice. We describe the use of a graded epidural anaesthesia technique, which proved to be a safe and effective method for managing a parturient with significant cardiac disease during caesarean section. This technique resulted in minimal hemodynamic changes and superior post-operative pain control and avoided potential side effects associated with general anaesthesia. Notably, the technique relied solely on a neuraxial anaesthetic technique, minimising the risk of neonatal cardiopulmonary depression. This case report serves as the first documented instance from South Africa of successfully anaesthetizing an adult patient with unrepaired TOF in late pregnancy for a caesarean section. The graded epidural technique emerged as a secure option for anaesthetic management in a challenging case, providing important insights into the care of patients with complex cardiac conditions during pregnancy.