Purpose: Management of hepatic mesenchymal hamartomas (MH) is challenging in the premature infant. We present three cases associated with placental mesenchymal dysplasia, highlighting the clinical challenges. Methodology: The medical records for each patient were retrospectively reviewed following consent being obtained. Results: Patient 1 (born 30+4/40) was antenatally found to have a large hepatic cystic lesion, leading to significant abdominal distension. Due to size/prematurity, percutaneous drainage was initially performed however multiple repeat procedures were required due to fluid re-accumulation. At 8 months they underwent laparotomy/resection of cystic lesions confirmed to be MH on histopathology, and remains under surveillance. Patient 2 (29+1/40); postnatal imaging demonstrated rapid growth of multifocal liver lesions leading to significant abdominal distension. Biopsy suggested infantile haemangioma and atenolol was commenced. Ongoing growth continued with massive hepatomegaly and so laparotomy/debulking of lesions was performed; macroscopically and histopathologically heterogenous (some MH and some haemangioma). They remain under surveillance for the residual lesions. Patient 3 (25+1/40); postnatal imaging demonstrated large hepatic cystic lesion. At 5 weeks due to respiratory deterioration the cyst was drained percutaneously and at 3 months laparotomy and de-roofing was performed confirming MH, this was complicated by bowel obstruction requiring ileostomy. Conclusion: Mesenchymal hamartoma in association with placental mesenchymal dysplasia is rare and can present a significant challenge in premature neonates. Management is guided by gestation/size and clinical status, as well as the nature of the lesions. In these three cases, emergent management was necessitated due to mass effect of the lesions, however surgical management options for each patient differed due to the contrasting nature of the lesions (cystic vs solid).