The placenta serves as the lungs, gut, kidneys, and liver of the fetus (Burton and Jauniaux, 2015; Maltepe and Fisher, 2015). This fetal organ also has major biological actions that modulate maternal physiology (Burton and Jauniaux, 2015; Sasaki and Norwitz, 2011; Taglauer et al., 2014; Fitzgerald et al., 2018) and, importantly, together with the extraplacental chorioamniotic membranes, shield the fetus against microbes from hematogenous dissemination and from invading the amniotic cavity (Ander et al., 2019; Kwon et al., 2014). Indeed, most pathogens that cause hematogenous infections in the mother cannot reach the fetus, which is largely due to the potent protective mechanisms provided by placental cells (i.e. trophoblast cells: syncytiotrophoblasts and cytotrophoblasts) (Parry et al., 1997; Koi et al., 2002; Arora et al., 2017). Yet, some of these pathogens such as Toxoplasma gondii, Rubella virus, herpesvirus (HSV), cytomegalovirus (CMV), and Zika virus (ZIKV), among others, are capable of crossing the placenta and infecting the fetus, thus causing congenital disease (Stegmann and Carey, 2002; Coyne and Lazear, 2016).

In December 2019, a local outbreak of pneumonia caused by a novel coronavirus—severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—was reported in Wuhan (Hubei, China) (Dong et al., 2020a). After exposure to SARS-COV-2, susceptible individuals can develop coronavirus disease 2019 (COVID-19) consisting of symptoms that may range from fever and cough to severe respiratory illness; in some cases, COVID-19 is life-threatening (Centers for Disease Control and Prevention, 2020a; Wadman, 2020). Since the onset of the outbreak, more than 10 million COVID-19 cases have been confirmed, accounting for more than 500,000 deaths (COVID-19, 2020). This pandemic has now spread throughout the entire world with recent epicenters in Europe (Italy and Spain) and the United States. By April 2019, the states of New York and Michigan were the most severely affected (COVID-19, 2020), given that the metropolitan areas of New York City and Detroit possess large populations subject to health disparities that include limited access to health care, chronic exposure to pollution, and pre-existing cardiovascular conditions (Centers for Disease Control and Prevention, 2020b).

Pregnant women and their fetuses represent a potential high-risk population in light of the COVID-19 outbreak (Dashraath et al., 2020; Liu et al., 2020; Rasmussen et al., 2020; Ashokka et al., 2020; Della Gatta et al., 2020; Weber LeBrun et al., 2020; Tekbali, 2020; Vintzileos, 2020; Lokken, 2020) given that viral infections such as influenza (Neuzil et al., 1998; Lindsay et al., 2006; Jamieson et al., 2006; Cervantes-Gonzalez and Launay, 2010; Pandemic H1N1 Influenza in Pregnancy Working Group et al., 2010; Mosby et al., 2011; Pazos et al., 2012; Raj et al., 2014), varicella (Triebwasser et al., 1967; Paryani and Arvin, 1986; Esmonde et al., 1989; Haake et al., 1990; Swamy and Dotters-Katz, 2019), Ebola (Olgun, 2018; Muehlenbachs et al., 2017), and measles (Christensen et al., 1954; Atmar et al., 1992) show increased severity in this physiological state. Other coronaviruses, such as SARS-CoV-1 and MERS-CoV, have severe effects in both the mother and the fetus, but vertical transmission has not been proven (Wong et al., 2004; Ng et al., 2006; Alserehi et al., 2016; Jeong et al., 2017), albeit these studies included very few cases. By contrast with the above-mentioned viral infections, only ~15% of pregnant women test positive for SARS-CoV-2 and a small fraction of them are symptomatic (Sutton et al., 2020), most of whom experience only a mild illness (Chen et al., 2020a). Consequently, the clinical characteristics of pregnant women with COVID-19 appear similar to those of non-pregnant adults (Yu et al., 2020). Yet, recent reports have shown that severe COVID-19 can lead to maternal death (Hantoushzadeh et al., 2020; Blitz, 2020). However, thus far, no conclusive evidence of vertical transmission has been generated (Weber LeBrun et al., 2020; Chen et al., 2020b; Stower, 2020; Lamouroux et al., 2020; Yan et al., 2020; Siberry et al., 2020). Consistently, infants born to mothers with COVID-19 test negative for SARS-CoV-2, do not develop serious clinical symptoms (e.g., fever, cough, diarrhea, or abnormal radiologic or hematologic evidence), and are promptly discharged from the hospital (Chen et al., 2020c). Nevertheless, new evidence has emerged suggesting that the fetus can respond to SARS-CoV-2 infection.

Case reports have shown that a small fraction of neonates born to women with COVID-19 tested positive for the virus at 1–4 days of life (Zeng et al., 2020a; Alzamora et al., 2020), yet these neonates subsequently tested negative on day 6-7 (Zeng et al., 2020a). In addition, serological studies revealed that a few neonates born to mothers with COVID-19 had increased concentrations of SARS-CoV-2 immunoglobulin (Ig)M as well as IgG (Zeng et al., 2020b; Dong et al., 2020b). The elevated concentrations of IgG are likely due to the passive transfer of this immunoglobulin from the mother to the fetus across the placenta. However, the increased levels of IgM suggest that the fetus was infected with SARS-CoV-2 given that this immunoglobulin cannot cross the placenta as a result of its large molecular weight. Nonetheless, all neonates included in the above-mentioned studies tested negative for the virus and did not present any symptoms (Zeng et al., 2020b; Dong et al., 2020b).

More recently, two case reports indicated that SARS-CoV-2 RNA has been detected in the amniotic fluid and placental tissues. In the first case report, the viral RNA was detected in amniotic fluid from a woman who was severely affected and died of COVID-19 (Zamaniyan, 2020). The premature neonate tested negative for SARS-CoV-2 after delivery but 24 hr later tested positive (Zamaniyan, 2020). In the second case report, the viral RNA was detected in the placenta and umbilical cord from a woman with severe pre-eclampsia, placental abruption, and other complications, yet none of the fetal tissues tested positive (Hosier, 2020). Therefore, whether SARS-CoV-2 can reach the fetus by crossing the placenta is still unclear.

Cell entry and the spread of SARS-CoV-2 are widely thought to depend on the angiotensin-converting enzyme 2 (ACE2) receptor (Shang et al., 2020; Wang et al., 2020a) and the serine protease TMPRSS2 (Hoffmann et al., 2020). In the study herein, we investigated whether the receptors responsible for SARS-CoV-2 infection are expressed in the human placenta (including the decidual tissues) throughout the three trimesters of pregnancy by using publicly available single-cell RNA-sequencing (scRNA-seq) data (Vento-Tormo et al., 2018; Pique-Regi et al., 2019) together with newly generated data (Supplementary file 1).

Strikingly, we found that very few cells co-express ACE2 and TMPRSS2 (Figure 1A and B). Using a very permissive threshold of expression of one transcript per cell, only four cells with co-expression were detected in any of the three trimesters, resulting in an estimated <1/10,000 cells. Our first-trimester data are in agreement with a prior report showing minimal expression of ACE2 at the human maternal-fetal interface (Zheng et al., 2020); however, the same dataset was recently used to report the opposite (Li et al., 2020). Nonetheless, the co-expression of ACE2 and TMPRSS2 was not examined by either study, and it is important to consider log-transformation and data analysis issues for low-expressed genes, focusing on the fraction of cells expressing the transcripts (Booeshaghi and Pachter, 2020). We also evaluated the expression of SARS-CoV2 receptors in the chorioamniotic membranes (also known as the extraplacental membranes) in the third trimester; these tissues may also serve as a point of entry for microbial invasion of the amniotic cavity and potentially the fetus (Kim et al., 2015). Again, co-expression of ACE2 and TMPRSS2 was minimally detected in the chorioamniotic membranes (Figure 1A and B).

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A challenge in scRNA-seq studies is generating high-quality, single-cell suspensions containing both rare and difficult-to-dissociate (e.g., multinucleated cells) cell types. This is likely the reason why the reported scRNA-seq studies of the human placenta contain a low fraction of syncytiotrophoblast cells [STB, multinucleated cells forming the outermost fetal component of the placenta in direct contact with the maternal circulation (i.e., intervillous space)] (Vento-Tormo et al., 2018; Pique-Regi et al., 2019; Tsang et al., 2017). Therefore, we considered whether the expression of ACE2 and TMPRSS2 was minimally observed in the placental cell types as a result of the reduced fraction of STB cells (i.e., dissociation bias). To address this possibility, we prepared single-nucleus suspensions of the placental tissues (including the decidua basalis) and performed single-nuclear RNAseq (snRNA-seq), which reduces the dissociation bias against large cells (Wu et al., 2019). An important advantage of snRNA-seq is its compatibility with biobank-frozen samples; therefore, we pooled 32 placental villi/decidua samples collected in the third trimester (Supplementary file 2). This represents the first snRNA-seq study of the placental tissues. As expected, a larger fraction of STB cells/nuclei was observed using snRNA-seq compared to scRNA-seq (Figure 1A and Figure 1—figure supplement 1). Consistent with the scRNAseq analyses, the snRNAseq data demonstrated that co-expression of ACE2 and TMPRSS2 is unlikely in the placental tissues (Figure 1B). A limitation of snRNA-seq is that it has a higher background compared to scRNAseq and could capture ACE2 and TMPRSS2 transcripts from other cell types, but this should not affect the analyses reported herein because co-expression is not observed.

Finally, we explored the expression of ACE2 and TMPRSS2 in third-trimester placental tissues by mining two microarray datasets that we have previously reported (Kim et al., 2009; Toft et al., 2008). These analyses of bulk gene expression data revealed that, while ACE2 was detected above background in most of the samples, TMPRSS2 was largely undetected (Supplementary file 3). Collectively, these results consistently indicate that the human placental tissues negligibly co-express ACE2 and TMPRSS2. This reduced expression contrasts with the high expression of ACE2 and TMPRSS2 in nasal goblet and ciliated cells within the human airways, lungs, and gastrointestinal tract, which are targeted during COVID-19 (Muus, 2020; Wang, 2020b; HCA Lung Biological Network et al., 2020). Therefore, our results suggest that vertical transmission of SARS-CoV-2 is unlikely to occur unless facilitated by other concomitant pathological conditions resulting in a breach of the maternal-fetal crosstalk.

There is a possibility, however, that SARS-CoV-2 could infect the human placenta by using alternate entry routes while interacting with other proteins (Gordon et al., 2020). The expression of additional SARS-CoV-2-related receptors or proteins in the human placenta is shown in Figure 2, CoV-Alt; however, further research is required to test their participation in the pathogenesis of COVID-19. For example, in vitro studies suggest that BSG (Basigin, also called CD147 or EMMPRIN, transmembrane glycoprotein belonging to the immunoglobulin superfamily) provides an alternate entry for SARS-CoV-2 when ACE2 and TMPRSS2 are not expressed (Blanco-Melo et al., 2020; Wang, 2020c; Ulrich and Pillat, 2020). We found that the placenta and chorioamniotic membranes expressed high levels of BSG throughout pregnancy (Figure 2, CoV-Alt), yet this transcript is also widely expressed in all human tissues and cell types (Figure 2—figure supplement 1). Therefore, it is unlikely that this protein alone is a sufficient requirement for SARS-CoV-2 viral entry, and other proteins may be required to explain the cell type primarily affected by COVID-19. Moreover, cathepsin L (CSTL) and FURIN may also function as proteases priming the SARS-CoV-2 S protein (Lukassen et al., 2020). We found that these proteases are highly expressed by the placental tissues throughout gestation (Figure 2, CoV-Alt). Nevertheless, these proteases may not provide sufficient levels of priming by themselves (Shirato et al., 2017; Shirato et al., 2018; Iwata-Yoshikawa et al., 2019) when tested with SARS-CoV-1, yet this has not been verified for SARS-CoV-2. Given that the placental tissues are enriched in maternal and fetal macrophages (Pique-Regi et al., 2019), and that a subset of these immune cells expressing sialoadhesin (SIGLEC1, also known as CD169) can contribute to viral spread during SARS-CoV-2 infection (Chen, 2020; Park, 2020), we also investigated the expression of SIGLEC1 in this study. As expected, SIGLEC1 was expressed by macrophages in the placenta and chorioamniotic membranes and, to a lesser extent, in T cells (Figure 2, CoV-Alt). However, even if the virus could infect the placental/decidual macrophages expressing SIGLEC1, this is not sufficient for viral spreading. The expression of ADAM17 was also investigated in the placental tissues as this metalloproteinase competes with TMPRSS2 in ACE2 processing (Heurich et al., 2014). The placenta and chorioamniotic membranes highly expressed ADAM17 (Figure 2—figure supplement 2); however, only cleavage by TMPRSS2 results in augmented SARS-S-driven cell entry (Heurich et al., 2014). While these CoV-Alt molecules may be used for SARS-CoV-2 infection, they are likely to be less efficient than ACE2 and TMPRSS2, which are already targeted for antiviral interventions (Hoffmann et al., 2020); yet, new candidate host:viral interacting proteins and possible drugs are being investigated (Gordon et al., 2020).

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Given that the main mediators for cell entry of SARS-CoV-2 were minimally expressed by the human placenta, we also investigated whether the receptors for congenital viruses such as CMV (Stegmann and Carey, 2002; Arechavaleta-Velasco et al., 2002; Aronoff et al., 2017; Pereira et al., 2017; Al-Haddad et al., 2019; Faure Bardon et al., 2020) and ZIKV (Coyne and Lazear, 2016; Adams Waldorf et al., 2016; Aldo et al., 2016; Cao et al., 2017; Aagaard et al., 2017; Mysorekar, 2017; Valentine et al., 2018; Adams Waldorf et al., 2018; Dudley et al., 2018; Walker et al., 2019; Nelson et al., 2020), which are known to infect and cross the placenta, were detectable using our pipeline. Known receptors for CMV include NRP2 (Martinez-Martin et al., 2018), PDFGRA (Martinez-Martin et al., 2018), and CD46 (Stein et al., 2019). Notably, all of these receptors were highly expressed in several placental cell types (Figure 2, CMV and Figure 2—figure supplement 2). Next, we investigated the expression of the AXL receptor for ZIKV (Richard et al., 2017; Persaud et al., 2018) as well as other related molecules such as CD209 (Carbaugh et al., 2019) and TYRO3 (Oliveira and Peron, 2019). Consistent with vertical transmission, AXL, the preferred receptor for ZIKV, was highly expressed by the cells of the human placenta and chorioamniotic membranes throughout gestation (Figure 2, ZIKV). The expression of CD209 was mainly found in the maternal and fetal macrophage subsets, as expected (Svensson et al., 2011; Swieboda et al., 2020). Yet, the expression of TYRO3 was low (Figure 2—figure supplement 2), consistent with the view that TAM receptors are not essential for ZIKV infection (Hastings et al., 2017). The expression of other viral receptors involved in congenital disease was also documented in the placental tissues (Figure 2—figure supplement 2).

Placenta and decidua scRNA-seq data from first-trimester samples were downloaded through ArrayExpress (E-MTAB-6701). Data for third-trimester samples previously collected by our group are available through NIH dbGAP (accession number phs001886.v2.p1), and newly generated second-trimester scRNA-seq and third-trimester snRNA-seq data are deposited in the same repository.

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Author details

1. Roger Pique-Regi

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Center for MolecularMedicine and Genetics, Wayne State University School of Medicine, Detroit, United States
   3. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Conceptualization, Resources, Data curation, Formal analysis, Supervision, Investigation, Visualization, Methodology, Writing - original draft, Writing - review and editing

   For correspondence

   rpique@wayne.edu

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-1262-2275

2. Roberto Romero

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Center for MolecularMedicine and Genetics, Wayne State University School of Medicine, Detroit, United States
   3. Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, United States
   4. Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, United States
   5. Detroit Medical Center, Detroit, United States
   6. Department of Obstetrics and Gynecology, Florida International University, Miami, United States

   Contribution

   Conceptualization, Supervision, Funding acquisition, Investigation, Methodology, Writing - original draft, Project administration, Writing - review and editing

   For correspondence

   prbchiefstaff@med.wayne.edu

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-4448-5121

3. Adi L Tarca

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States
   3. Department of Computer Science, Wayne State University College of Engineering, Detroit, United States

   Contribution

   Resources, Data curation, Formal analysis, Methodology, Writing - original draft, Writing - review and editing

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0003-1712-7588

4. Francesca Luca

   1. Center for MolecularMedicine and Genetics, Wayne State University School of Medicine, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Resources, Data curation, Supervision, Investigation, Methodology, Writing - original draft, Writing - review and editing

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0001-8252-9052

5. Yi Xu

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Resources, Data curation, Formal analysis, Validation, Methodology, Writing - review and editing

   Competing interests

   No competing interests declared

6. Adnan Alazizi

   Center for MolecularMedicine and Genetics, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Data curation, Validation, Methodology, Writing - review and editing

   Competing interests

   No competing interests declared

7. Yaozhu Leng

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Resources, Data curation, Methodology, Writing - review and editing

   Competing interests

   No competing interests declared

8. Chaur-Dong Hsu

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States
   3. Department of Physiology, Wayne State University School of Medicine, Detroit, United States

   Contribution

   Resources, Project administration, Writing - review and editing

   Competing interests

   No competing interests declared

9. Nardhy Gomez-Lopez

   1. Perinatology Research Branch, Divisionof Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, United States
   2. Department ofObstetrics and Gynecology, Wayne State University School of Medicine, Detroit, United States
   3. Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, United States

   Contribution

   Conceptualization, Data curation, Supervision, Investigation, Writing - original draft, Writing - review and editing

   For correspondence

   ngomezlo@med.wayne.edu

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-3406-5262

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