Pregnant women are at greater risk of adverse outcomes, including mortality, as well as obstetrical complications resulting from COVID-19. However, pregnancy-specific changes that underlie such worsened outcomes remain unclear. Plasma samples were collected from pregnant women and non-pregnant individuals (male and female) with (n=72 pregnant, 52 non-pregnant) and without (n = 29 pregnant, 41 non-pregnant) COVID-19. COVID-19 patients were grouped as asymptomatic, mild, moderate, severe, or critically ill according to NIH classifications. Proteomic profiling of 7,288 analytes corresponding to 6,596 unique protein targets was performed using the SOMAmer platform. Herein, we profile the plasma proteome of pregnant and non-pregnant COVID-19 patients and controls and show alterations that display a dose-response relationship with disease severity; yet, such proteomic perturbations are dampened during pregnancy. In both pregnant and non-pregnant state, the proteome response induced by COVID-19 shows enrichment of mediators implicated in cytokine storm, endothelial dysfunction, and angiogenesis. Shared and pregnancy-specific proteomic changes are identified: pregnant women display a tailored response that may protect the conceptus from heightened inflammation, while non-pregnant individuals display a stronger response to repel infection. Furthermore, the plasma proteome can accurately identify COVID-19 patients, even when asymptomatic or with mild symptoms. This study represents the most comprehensive characterization of the plasma proteome of pregnant and non-pregnant COVID-19 patients. Our findings emphasize the distinct immune modulation between the non-pregnant and pregnant states, providing insight into the pathogenesis of COVID-19 as well as a potential explanation for the more severe outcomes observed in pregnant women.

Nardhy Gomez-Lopez, Roberto Romero, María Fernanda Escobar, Javier Andres Carvajal, Maria Paula Echavarria, Ludwig L. Albornoz, Daniela Nasner, Derek Miller, Dahiana M. Gallo, Jose Galaz, Marcia Arenas-Hernandez, Gaurav Bhatti, Bogdan Done, Maria Andrea Zambrano, Isabella Ramos, Paula Andrea Fernandez, Leandro Posada, Tinnakorn Chaiworapongsa, Eunjung Jung, Valeria Garcia-Flores, Manaphat Suksai, Francesca Gotsch, Mariachiara Bosco, Nandor Gabor Than, Adi L. Tarca