Sulfated progesterone metabolite (P4-S) levels are raised in normal pregnancy and elevated further in intrahepatic cholestasis of pregnancy (ICP), a bile acid-liver disorder of pregnancy. ICP can be complicated by preterm labor and intrauterine death. The impact of P4-S on bile acid uptake was studied using two experimental models of hepatic uptake of bile acids, namely cultured primary human hepatocytes (PHH) and Na ؉ -taurocholate co-transporting polypeptide (NTCP)-expressing Xenopus laevis oocytes. Two P4-S compounds, allopregnanolone-sulfate (PM4-S) and epiallopregnanolone-sulfate (PM5-S), reduced [ 3 H]taurocholate (TC) uptake in a dose-dependent manner in PHH, with both Na ؉ -dependent and -independent bile acid uptake systems significantly inhibited. PM5-S-mediated inhibition of TC uptake could be reversed by increasing the TC concentration against a fixed PM5-S dose indicating competitive inhibition. Experiments using NTCP-expressing Xenopus oocytes confirmed that PM4-S/PM5-S are capable of competitively inhibiting NTCPmediated uptake of [ 3 H]TC. Total serum PM4-S ؉ PM5-S levels were measured in non-pregnant and third trimester pregnant women using liquid chromatography-electrospray tandem mass spectrometry and were increased in pregnant women, at levels capable of inhibiting TC uptake. In conclusion, pregnancy levels of P4-S can inhibit Na ؉ -dependent and -independent influx of taurocholate in PHH and cause competitive inhibition of NTCP-mediated uptake of taurocholate in Xenopus oocytes.Normal pregnancy is characterized by altered bile acid homeostasis, and two recent studies have reported asymptomatic hypercholanemia of pregnancy in 10 -40% of pregnant women (1, 2). Approximately 25% of women with asymptomatic hypercholanemia of pregnancy subsequently develop intrahepatic cholestasis of pregnancy (ICP), 4 a liver disorder that presents with pruritus, raised serum bile acids, and liver transaminases (3). In pregnancies complicated by maternal serum bile acid levels of Ͼ40 M, there are increased rates of spontaneous preterm labor, fetal asphyxial events, and meconium-stained amniotic fluid (3). ICP may also be complicated by third trimester intrauterine death (3, 4).ICP has a complex etiology with genetic and endocrine components. Parous sisters have a 12-fold increased risk (5), and in ϳ10% of ICP cases, mutations have been identified in genes that encode biliary transporters (6 -9) and the primary bile acid sensor farnesoid X receptor (NR1H4) (10). Furthermore, the V444A polymorphism in the ABCB11 gene is a population risk factor for ICP (8), and ICP patients homozygous for the polymorphism have been shown to have increased bile acid levels when compared with controls (11).Cholestatic metabolites of estrogen and progesterone influence bile acid metabolism and transport. A subgroup of women with a history of ICP who take the oral contraceptive pill or exogenous estrogens develop pruritus and hepatic impairment (4). In addition, administration of oral micronized natural progesterone for prophylaxis of...