Haemangiomas are vascular lesions that occur when endothelial vascular cells form abnormally and multiply more than they should . They can be congenital (CHs) which are rare comprising 3% of cases and present at birth, or infantile haemangiomas (IHs) where they appear later in infancy and affect 4-5% of newborn infants . Congenital haemangiomas may solely occur or can be a part of multiple malformations, the most common of which is Kasabach-Merritt syndrome with associated thrombocytopenia and coagulopathy  and PHACES syndrome . They can be complicated with life-threatening bleeding and high-output heart failure .
According to the International Society of the Study of Vascular Anomalies (ISSVA) classification, vascular malformations are subdivided according to vessel type into high-flow lesions as arteriovenous malformations, low-flow lesions that can be venous, lymphatic, or mixed and capillary malformations as port-wine stains. Also congenital haemangiomas (CH) were classified into rapidly involuting congenital haemangiomas (RICHs), partially-involuting congenital haemangiomas (PICHs) and non-involuting congenital haemangiomas (NICHs) . CHs most commonly affect the liver and cutaneous tissues where differential diagnoses include pyogenic granulomas, macrocystic lymphatic malformation and malignant tumors as sarcoma, cutaneous neuroblastoma and lymphoma .
Big size CHs are often diagnosed antenatally using ultrasonography where they usually appear as hypoechoic lesions compared to HIs that appear postnatally as isoechoic lesions . Also on Doppler ultrasound, CH appear as a vascular mass, composed mostly of veins unlike IH . The imaging findings of fetal upper limb hemangioma tumors may widely overlap, the early detection and prenatal follow up of these tumors are very important for fetal, maternal, and postnatal care.
The main differentials in our case were CH and arterio-venous malformations (AVMs) of the upper limb and since biopsy may result in massive haemorrhage, diagnosis is most often based on characteristic radiological findings of usually well-defined mixed, solid lesions with hypervascularisation and fine granular calcifications . Although hemangiomas have been reported hyperechoic or isoechoic , our case showed a mutli-septated complex cystic structure with low resistance flow together with peripheral dilated vessels (Fig. 1b) which suggested of CH using 2D, 4D sonography and Doppler studies at 27 weeks of gestation rather than AVMs which characteristically appear as echogenic dilated vascular channels replacing cutaneous tissue parenchyma with high-flow Doppler characteristics that lack arterial pulsation.
Management of congenital hemangiomas is patient-specific and highly dependent on the size, location, ability to involute, and presence of complications. RICHs are self-resolving and usually expectantly managed, unless complications such as ulceration, infection or bleeding occur. Once involution is complete, the fibro-fatty residual tissue may be excised to enhance cosmesis .
Treatment for patients with both high-flow and low-flow malformations is either expectant, medical, surgical, endovascular intervention or laser therapy. Only a low level of evidence supports the choice of treatment between these options, and the recurrence rates for large lesions are relatively high .
The majority of RICHs completely involute by 14 months however in our case the regression was faster and was complete by the age of 5 months with expectant management helped with oral propranolol .