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Postpartum Hemorrhage

Hard

Clinical Presentation

A 30-year-old primigravida delivered a 3.5 kg baby vaginally 30 minutes ago. The placenta has been delivered. Now there is profuse vaginal bleeding. The uterus is boggy and poorly contracted despite uterine massage. Estimated blood loss is 800 mL and ongoing. BP 90/60, HR 120.

What is the most likely cause of this PPH?